Assessment and management of chronic kidney disease in...
94
CHRONIC KIDNEY DISEASE IN PRIMARY CARE JENNIFER SEBES DNP, APRN, FNP-C
Assessment and management of chronic kidney disease in ...webs.wichita.edu/depttools/depttoolsmemberfiles/conferences... · SPEP, UPEP with immunofixation, serum free light chains
CKD AS A PUBLIC HEALTH ISSUEbull 26 million American affectedbull Prevalence is 1 out of 9 peoplebull 28 of Medicare budget in 2013 up from 69 in 1993bull $gt50 billion in 2016bull Increases risk for all-cause mortality CV mortality kidney failure (ESRD) and
other adverse outcomesbull 6 fold increase in mortality rate with DM + CKDbull Disproportionately affects African Americans and Hispanics
1 NKF Fact Sheets httpwwwkidneyorgnewsnewsroomfactsheetsFastFacts Accessed Nov 5 20142 USRDS wwwusrdsorg Accessed Nov 5 20143 Coresh et al JAMA 2007 2982038-2047
Table 63 Adjusted survival () by treatment modality and incident cohort year (year of ESRD onset) Dialysis
USRDS 2016 Annual Data Report Vol 2 ESRD Ch 6
3
Data Source Reference Tables I1_adj-I36_adj Adjusted survival probabilities from day one in the ESRD population Reference population incident ESRD patients 2011 Adjusted for age sex race Hispanic ethnicity and primary diagnosis Abbreviation ESRD end-stage renal disease
bull Structural or functional abnormalities of the kidneys with our without decreased GFR manifest by either
bull Pathological abnormalities
bull Markers of kidney damage including abnormalities in the composition of the blood or urine or in imaging tests
bull GFR lt 60 mlmin173 m2 for gt 3 months with or without kidney damage as defined above
(Kidney Disease Improving Global Outcomes (KDIGO) CKD Work Group 2013)
CKD RISK FACTORS
Modifiablebull Diabetesbull Hypertensionbull History of AKIbull Frequent NSAID use
bull Obesity
bull Hyperuricemia
bull Smoking
bull Sedentary lifestyle
bull Dietary Protein Intake
Non-modifiablebull Family history of kidney disease diabetes or
hypertension
bull Age 60 or older (GFR declines normally with age)
bull RaceUS ethnic minority status
Partial listAKI acute kidney injury (Kidney Disease Improving Global Outcomes (KDIGO) CKD Work Group 2013)
GAPS IN CKD DIAGNOSIS
Szczech Lynda A et al Primary Care Detection of Chronic Kidney Disease in Adults with Type-2 Diabetes The ADD-CKD Study (Awareness Detection and Drug Therapy in Type-2 Diabetes and Chronic Kidney Disease) PLOS One - In press (2014)
0
10
20
30
40
50
60
Not Appropriately Tested Appropriately tested - no diagnosis Appropriately tested - accurate diagnosis
CKD Screening in Primary Care( of patients)
of Patients
Improved Diagnosishellip
Studies demonstrate that clinician behavior changes when CKD diagnosis improves Significant improvements realized in1-3
bull Increased urinary albumin testingbull Increased appropriate use of ACEi or ARBbull Avoidance of NSAIDs prescribing among patients
with low eGFRbull Appropriate nephrology consultation
1 Wei L et al Kidney Int 201384174-1782 Chan M et al Am J Med 20071201063-10703 Fink J et al Am J Kidney Dis 200953681-668
STEPS TO CKD PATIENT CARE
1 CKD definition and risks2 Assess GFR albuminuria (knowing the labs)3 Determine etiology4 Slow progression5 Assess for associated complications6 Discuss dialysistransplantation
CREATININEbull Creatinine is derived from the metabolism of creatine in skeletal
muscle and from dietary meat intake
creatinine secretion by the renal tubules + creatine intake (ie diet)+ creatinine pool size (ie muscle mass) all remain constant
bull GFR is equal to the sum of the filtration rates in all of the functioning nephrons
bull Glomeruli filter 180Lday (125mLmin) of plasma
bull Normal GFR depends on age sex body size and is approximately 130mLmin for men and 120mLmin for womenmdashwith considerable variation
bull CKD-EPI equation (estimated GFR in mLmin173m2) is most accurate
Age Gender RaceSCr
(mgdL) eGFR (mLmin173 m2)
20 M B 13 91
20 M W 13 75
55 M W 13 61
20 F W 13 56
55 F B 13 55
50 F W 13 46
B = black W = all ethnic groups other than blackWith evidence of kidney damage
(Duncan Heathcoat Djurdjev amp Levin 2001)(National Kidney Foundation 2002)
or lt 15 mLmin173m2
(Levey et al 2009)
True GFR could be gt 70 mLmin173m2
The ldquoerdquo in eGFR Stands for ldquoEstimatedrdquohellip
USE THESE EQUATIONS CAUTIOUSLY IF AT ALL IN hellip
bull Patients who haveare
bull Poor nutritionloss of muscle mass
bull Amputation
bull Chronic illness
bull Not African American or Caucasian
bull Changing serum creatinine
bull Obese
bull Very elderly young
(National Kidney Foundation 2014)
LAB ALBUMIN CREATININE RATIO
bull Urinary albumin-to-creatinine ratio (ACR) is calculated by dividing albumin concentration in milligrams by creatinine concentration in grams
bull Creatinine assists in adjusting albumin levels for varying urine concentrations which allows for more accurate results versus albumin alone
bull Spot urine albumin-to-creatinine ratio for quantification of proteinuria
bull New guidelines classify albuminuria as mild moderately or severely increased
bull First morning void preferable
bull 24hr urine test rarely necessary
THE NEW CKD CATEGORIES
STEPS TO CKD PATIENT CARE
1 CKD definition and risks2 Assess GFR albuminuria3 Determine etiology- what is going on here4 Slow progression5 Assess for associated complications6 Discuss dialysistransplantation
(Pal 2012)
KIDNEY INVOLVEMENT IN SYSTEMIC DISEASES
Hypertension
DiabetesAmyloidosis
Sickle cell diseases
Immune complex GN
Illicit drugs ndash cocaine heroin
Cholesterol emboli
HIV
Allergic reactions- drugsinterstitial nephritis
Hemolytic Uremic syndrome
Lupus
Systemic vasculitis
Liver FailureCongestive heart Failure
Image retrieved on 05 October 2010 from httpenwikipediaorgwikiFileGray1129pngThis image is under the public domain and not copyrightable in the US as per Bridgeman Art Library v Corel Corp
(Vasudev amp Vasudev 2012)
New CKD
Obtain ultrasound UA
microscopy albumincr ratio
Ultrasound shows
obstruction
bull Yes Relieve obstruction
bull No Is there albuminuria or glomerular bleeding (eval for glomerulo-nephritis
Fatehi amp Chi-yuan 2016
If red cells have their typical shape and color this indicates extra glomerular hematuria
Examples kidney stone disease UTI cystitis bleeding from collecting duct ureters bladder or urethra
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileReactive_lymphJPGCreative Commons License associated httpcreativecommonsorglicensesby-sa30deeden
(Vasudev amp Vasudev 2012)
DYSMORPHICRENAL HEMATURIA
bull This hematuria is characterized by bull a great variation in the size of the cells and by a high
percentage of dysmorphocytosiscasts (gt20)
bull Hematuria is usually related to glomerular bleeding bull It is typically accompanied by variable levels of albumuniuria
(Vasudev amp Vasudev 2012)
Urinary Cast Formation
Urine Microscopy can be helpful in work up of chronic kidney disease
In GNrsquos the red blood cells leak from the glomerulus into the tubules As they traverse through the tubules they can form cylindrical casts calledRBC casts
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileRedbloodcellsjpgThis image is a work of the National Institutes of Health part of the United States Department of Health and Human Services As a work of the US federal government the image is in the public domain
(Vasudev amp Vasudev 2012)
IF YOU HAVE ALBUMINURIA OR HEMATURIA-ORDER THE FOLLOWING LABS
Tests of autoimmunity Hepatitis serologies gt40 years- paraproteinassessment
ANA Hepatitis B serology (HBsAG)
Serum protein electrophoresis (SPEP)
RFanti-ccp Hepatitis C serology(HCV antibody)
Urine protein electrophoresis (UPEP)
Complement C3 C4
ANCANational Kidney Disease Education Program 2014 NIH
UPTODATE LAB RECOMENDATIONS
bull Lab to order cbc cmp urine albumincr ratio urine microscopy
bull Nephrotic pattern (protein gt35gday) ANA anti DS DNA C3 and C4 antibodies HIV HBV HCV serumurine immunofixation (amyloidosis) free light chain analysis (light chain deposition disease)
bull Nephritic pattern (red cells white cells casts variable protein) C3 C4 ANA dsDNA antineutrophil cytoplasmic antibody (ANCA) titers a streptozyme test HBV and HCV serologies HIV and in some cases blood cultures anti-glomerular basement membrane (GBM) antibodies and cryoglobulins
bull Renal biopsy(Hebert amp Parikh 2014)
EVALUATION OF NEW CKDNO OBSTRUCTION
NO EVIDENCE OF GLOMERULAR BLEEDING
High risk for multmyeloma (gt40
no nsaids no contrast
SPEP UPEP with immunofixation serum free light
chains
Evaluation depends on UA
Sterile pyuria
Eval for interstitial nephritis
Normal urinalysis
High risk for renovascular
disease
Eval for renovascular
disease
Follow serum creatinine-does it
remain stable(Fatehi amp Chi-yuan 2016)
POSSIBLE INVESTIGATIONShellip
Acute interstitial nephritisbull Drugs are the most common cause of AIN
DIABETIC NEPHROPATHY 1 CAUSE OF CKDbull Clinical syndromebull Albuminuria gt30 mg 24 hrsbull Proteinuria gt500 mg24 hrsbull Hypertension developsbull Progressive increase in proteinuriabull Progressive decline in glomerular filtration rate
bull Chronic kidney disease should be attributed to diabetic nephropathies in most patients with diabetes if albuminuria and diabetic retinopathy are both present other causes of CKD should be entertained if diabetic retinopathy is absent (KDIGO 2007)
DIABETIC NEPHROPATHY MORTALITY
bull After 40 yrs of DM
bull 10 alive if proteinuria is present
bull 70 alive if proteinuria is absent
bull Heart Disease is 15 times higher risk in those with proteinuria
bull Proteinuria = death in this population
Dunkler et al 2015
GOALS OF CARE IN CKD GLUCOSE CONTROL
bull Target HbA1c ~70 (lt695 greatest chance of reducing albuminuria)bull Can be extended above 70 with comorbidities or limited life expectancy and
risk of hypoglycemiabull Risk of hypoglycemia increases as kidney function becomes impairedbull Declining kidney function may necessitate changes to diabetes medications and
bull Just having HTN can cause proteinuriabull Usually 1-2 gms of protein a daybull Treat them like a diabetic with ACEI or ARBS and tight blood
pressure controlbull JNC-8 goal lt14090 for ptrsquos with CKDbull National kidney foundation lt14090 if ckd and no proteinuria
lt13080 if proteinuria present
(James Ortiz amp Et Al 2014)
TREATING HYPERTENSIONPROTEINURIA ACEI ORARBbull Riskbenefit should be carefully assessed in the elderly and medically fragilebull Check labs after initiation
bull If less than 30 SCr increase continue and monitorbull If more than 30 SCr increase stop ACEi and evaluate for renal artery stenosis
bull Continue until contraindication arises no absolute eGFR cutoffbull Better proteinuria suppression with low Na diet and diureticsbull Avoid volume depletionbull Avoid ACEi and ARB in combination12
bull Risk of adverse events (impaired kidney function hyperkalemia)
(Kunz Friedrich Wolbers amp Mann 2008)(Mann Schmieder amp McQueen 2008)
bull In adults gt50 yrs statin when eGFR ge 60 mlmin173m2 statin or statinezetimibe combination when eGFR lt 60 mlmin173m2
bull In adults lt 50 yrs statin if history of known CAD MI DM strokebull Aspirin is indicated for secondary but not primary prevention
Kidney Disease Improving Global Outcomes (KDIGO) CKD Work Group Kidney Int Suppls 201331-150
STATINS-RENOPROTECTIVECONTROVERSY
bull HMG-CoA reductase inhibitors (statins) in high doses can cause proteinuria
bull Possibly associated with less inflammation endothelial dysfunction and scarring in the kidney because they also block inflammatory cytokines
bull Use statins for CV disease not to treat proteinuria
(Afzali and Goldsmith 2016)
MEDICINE CAUTION
bull Hold metformin when gfr lt35 mlmin
bull GFR lt50 mlmin should alert to check all doses of meds
bull No bisphosphanates lt35 mlmin
bull No NSAIDScox 2 inhibitors lt60 mlmin
bull Atenolol ndashrenal excretion
bull BACTRIM A lot of AKI
MEDICINE CAUTION
bull Lovenox-use subcut heparinbull Apixibanbull Dabigatranbull Rivaroxibanbull Lithiumbull GABAPENTIN (ckd 4 max 300mg qd ckd 5 max 300mg qod)
STEPS TO CKD PATIENT CARE
1 CKD definition and risks2 Assess GFR albuminuria3 Determine etiology4 Assess for evidence of progression5 Assess for associated complications6 Discuss dialysistransplantation
CKD-CVD-DIABETES LINK CKD IS A DISEASE MULTIPLIER
National kidney foundation 2014
KDIGO 2017
CKD-MINERAL BONE DISORDERS
bull As kidneys fail they
bull Stop activating calcitriol (the active form of Vit D)mdashcausing calcium imbalance
bull Do not remove phosphorus from bloodmdashleading to phosphorus retention
bull The extra phosphorus pulls calcium out of bones causing them to weaken
bull High phosphorus stimulates PTH release
bull These changes (plus others) cause the start of secondary hyperparathyroidism
bull Labs
bull eGFR
bull Calcium
bull Phos
bull Vit D
bull iPTH
(Qunibi amp Henrich 2017)
PREVALENCE OF ABNORMALITIES OF MINERAL METABOLISM PTH IN CKD
bull Progression of disease ndash declining eGFR increasing proteinuria
bull Degree of proteinuria nephrotic syndrome gt 05-10 gd on ACEi or ARB therapy
bull Etiology of CKD not certain
bull Need help with disease management
bull Indications for kidney biopsy
Rosenberg 2016
WHEN TO REFER
STEPS TO CKD PATIENT CARE
1 CKD definition and risks2 Assess GFR albuminuria3 Determine etiology4 Assess for evidence of progression5 Assess for associated complications6 Discuss dialysistransplantation
KIDNEY TRANSPLANTATION
bull Treatment of choice for ESRDbull Improves quality of lifebull Waiting list time varies-3-5 yearsbull 3 year survival rate after transplantation is 83-94bull Increased risk of cancer
STARTING DIALYSIS IN THE ELDERLYhellipOR NOT
bull Among patients gt 75 yrs with stage 5 CKD who chose to NOT start dialysisbull Overall more likely to die over next 1-2 years bull But if they had ischemic heart disease or other significant comorbidity NO
DIFFERENCE in survival
bull Active disease management and supportive care may be appropriate without starting dialysis in the ill elderly
bull Palliative care does not mean ldquono carerdquo
bull Must have end-of-life discussions
(Murtagh et al 2007)
CKD MANAGEMENTbull Diagnose cause and treat underlying conditionbull Stage per guidelinesbull Slow progression of kidney disease (ACE inhibitors)bull Monitor for complicationsmdashvolume overload hyperkalemia metabolic acidosis
hyperphosphatemia anorexia fatigue htn bone diseasebull Labs cmp cbc phos Vit D 25OH iPTH urine microscopy uric acid urine
proteincr ratio-frequency based off heat map Get sono at least oncebull Vaccinate influenza hep B pneumococcalbull Eval ASCVD risk-likely needs statinbull Possible dexa (donrsquot give bisphosphonates if GFRlt35 let specialist manage)bull Refer to nephrology when eGFR is lt30 (sometimes if higher risk-refer earlier)
CASE 1
bull 55 year old man with past medical history of headaches presents to your office for his first time visit to a PCP in over 30 years
bull He has no past history of being admitted to the hospital and he does not take any OTC medsNSAIDsherbal meds He has no history of ETOH abuse smoking or drug use
bull Vitals BP 180100 mmHg pulse 80 R 18
bull Exam No JVD S1S2 regular PMI shifted to the left no gallop no abdominal bruit pulses bilaterally equal and regular no leg edema
bull What would you order
bull EKG cbc cmp ua urine proteincr ratio lipid
LAB RESULTS
bull Labs reveal a creatinine of 22 mgdL eGFR 33 Urine shows no blood or casts Urineprotein ratio shows 1 gm protein24 hrs EKG shows LVH
bull Next step in workupbull Renal ultrasound 1st then SPEP UPEP with immunofixation serum free light chains
bull Additional labs neg Renal ultrasound shows that both kidneys are slightly reduced in size and are mildly echogenic with no mass or hydronephrosis
bull What is your diagnosis
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileMain_complications_of_persistent_high_blood_pressurepngCreative Commons License associated httpcreativecommonsorglicensesby-sa30
bull 3 months Howevermdashwe have evidence of structural abnormalities Could potentially stage at G3b A3 (red on the heat map)
bull Goal blood pressure
bull JNC 8 14090 NKF 13080
bull Additional lab needed for progression monitoring
bull Cbc renal panel phos Vit D iPTH uric acid urine micro (we already have the renal sono and urine proteincr ratio and lipid)
Selective renal angiography (left lower renal artery) after successful percutaneous balloon dilatation of the stenotic lesionFibromuscular dysplasia in an accessory renal artery causing renovascular hypertension
Secondary Hypertension
Images retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileRenal_FMD2jpg and httpcommonswikimediaorgwikiFileRenal_FMDjpgCreative Commons License associated httpcreativecommonsorglicensesby20deeden (both images)
CASE 2bull OS is a 64year old Hispanic female in for DM check She has had DM for 15+ years and is currently
taking metformin 1000mg bid Lisinopril 10mg a day atorvastatin 40mg a day Labs today showed the following
bull Hgba1c 86 cmp eGFR 50 lipid WNL proteincr ratio 650mg These results are similar to her last visit
bull Upon further hx-you find that she had a recent eye exam and has mild nonproliferaive retinopathy She does not have neuropathy or other ss
bull What further workup do you need
bull Renal sonogram urine micro iPTH vit D (25 OH) phos uric acid
bull Dx stage
bull G3a A3
bull What further treatment do you need
bull Improve glycemic control Increase Lisinopril to 20mg with a goal of 40mg Avoid NSAIDs or other nephrotoxic agents make sure meds are renally dosed monitor 3xyear nephro referral
MANAGEMENT OF CKD IN DIABETESeGFR Recommended
All patients
Yearly measurement of creatinine urinary albumin excretion potassium
45-60 Referral to a nephrologist if possibility for nondiabetickidney disease existsConsider dose adjustment of medicationsMonitor eGFR every 6 monthsMonitor electrolytes bicarbonate hemoglobin calcium phosphorus parathyroid hormone at least yearly
Assure vitamin D sufficiencyConsider bone density testingReferral for dietary counselling
American Diabetes Association Standards of Medical Care in Diabetes Microvascular complications and foot care Diabetes Care 2017 40 (Suppl 1) S88-S98
CASE 3
bull 19 year old African American woman presents to your clinic with complaints of fatigue joint pains a new rash on her face oral ulcer
bull On exam BP 15080 P 88 Afebrile 96 O2 sats on RAbull GEN No respiratory distress at restbull HEENT painless oral ulcer flat rash over malar eminences sparing the nasolabial fold pallor +bull Lungs CTAbull CVS S1S2 regularbull Abdomen soft NTbull Ext left elbow joint and bilateral wrist joints are swollen and tender
bull What would you orderbull CBC CMP ua urine microscopy (microalbumin or urine proteincr ratio) ANA esr RF anti-ccp uric acid TSH
CASE 3
bull Working dx fatigue oral ulcer joint pain
bull Basic Labs Na 135 K 55 Bicarb 18 BUN 50 Cr 35 eGFR 22 Ca 90 ANA + titer 1640
bull UA 3+ blood 3+ protein RBC casts +
bull Given these results what is the most likely diagnosis
bull What would you do
SYSTEMIC LUPUS ERYTHEMATOSUS (SLE)
bull SLE multisystemic disease Etiology unknown
bull Production of autoantibodies and immune complexes formation
bull There is renal involvement in the great majority of patients with SLE at some time of the evolution 66-90
SLE ndash LUPUS NEPHRITIS
bull Race SLE is more commonsevere in African americans than Caucasiansbull
bull Gender female-to-male ratio of 91
bull Age Most patients develop lupus nephritis early in their disease course SLE is more common among women in the third decade of life and lupus nephritis occurs in patients aged 20-40 years
bull Kidney Biopsy For staging lupus nephritis (Class 1-5)
CASE 5bull A 80 year old man who has not seen a PCP in many years
presents to your clinic for weakness for the past few months On further questioning he tells you that his bones also have been hurting lately and he has developed leg swelling in the past month or so
bull On exam bull BP 16090 P 88 Afebrilebull GEN Thin built manbull HEENT pallor presentbull Lungs clearbull CVS S1S2 regular no rub or gallopbull Abdomen soft NTbull Ext 2 + edema
CASE 5
bull Differentials
bull CHF MI Cancer arthritis
bull Labs
bull CBC CMP urine microscopy urine proteincr ratio ESR TSH EKG BNP pa and lat CXR
bull LABS Urine dipstick negative for protein or blood
bull Basic chem bull Na 136 (135-145) K 51 (35-55) Chloride 108 (96-106) Bicarb 25
Given this presentation and the labs (low anion gap and elevated calcium anemia kidney failure) what will you think of What will you order next
Serum and urine protein electrophoresis
Intratubular refractile casts with surrounding syncytial giant cell reaction with chronic tubulointerstitial nephritis and fibrosis characteristic of myeloma cast nephropathy
Kidney Biopsy
CASE STUDYbull A 35 year old African American woman was seen in the clinic for
chronic cough and dyspnea on exertion She gave history of vague symptoms of fatigue and weight loss of 20 Ibs over the last six months
bull List some differentialsbull TB sarcoid lupus thyroid problems PEbull What would you orderbull PPD cbc cmp UA TSH ANA pa and lat cxr
bull Her labs were significant for mildly elevated calcium level and a creatinine of 20 mgdL eGFR 37
bull She had 750 mg of proteinuriaday
bull PPD neg ANA neg TSH and other labs WNL
bull Assuming this is present more than 3 monthshelliphellipwhat is her ckd stage
bull G3b A3
bull What do we still need
CT scan of chest
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileAnterior_mediastinal_mass_thymomajpgCreative Commons License associated httpcreativecommonsorglicensesby20deeden
CXR ndash HILAR LYMPHADENOPATHY
WHATS NEEDED NEXT
bull Biopsy of hilar lymphadenopathy or renal biopsy
bull DX sarcoidosis
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileSarcoidosis_signs_and_symptomsjpgThis work is in the public domain in the United States because it is a work of the United States Federal Government under the terms of Title 17 Chapter 1 Section 105 of the US Code
NEWLY DX CKD
bull 1) urinalysis microscopy ultrasound proteincr ratio
bull If obstruction-treat
bull No obstruction
bull Hx critical (consider myeloma if high risk)
bull glomerular bleeding or albumin in urine
bull Yes workup for glomerular causes (ANArf hep B C upep spep ANCA complement C3 C4)
bull No sterile pyruria-consider interstitial nephritis
bull High risk renovascular disease Evaluate renovascular disease
Additional Online Resources for CKD LearningbullNational Kidney Foundation wwwkidneyorgbullUnited States Renal Data Service wwwusrdsorgbullCDCrsquos CKD Surveillance Project
httpnccdcdcgovckdbullNational Kidney Disease Education Program
(NKDEP) httpnkdepnihgov
BIBLIOGRAPHY
bull Afzali B amp Goldsmith D J (2016 June 29) Statins and chronic kidney disease (G C Curhan amp A M Sheridan Eds) Retrieved 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsstatins-and-chronic-kidney-disease
bull American Diabetes Association Standards of Medical Care in Diabetes (2017) Microvascular complications and foot care Diabetes Care 2017 (40) S88-S98
bull American Diabetes Association Standards of Medical Care in Diabetes (2017) Microvascular complications and foot care Diabetes Care 40 (suppl 1) S88-S98
bull Berns J S (2017 Mar 22) Treatment of anemia in nondialysis chronic kidney disease (T A Golper amp A M Sheridan Eds) Retrieved from UpToDate httpswww-uptodate-comproxywichitaeducontentstreatment-of-anemia-in-nondialysis-chronic-kidney-disease
bull Chan M Dall A T Fletcher K E Lu N amp Trivedi H (2007) Outcomes in patients with chronic kidney disease referred late to nephrologists a meta-analysis American Journal of Medicine 120(12) 1063-1070
bull Coresh J Selvin E amp Stevens L A (2007) Prevalence of chronic kidny disease in the United States JAMA 298(17) doi101001jama298172038
bull de Brito-Ashurst I Varagunam M Raftery M amp Yagoob M (2009) Bicarbonate supplementation slows progression of CKD and improves nutritional status Journal of American Society of Nephrology (20) 2075-2084
BIBLIOGRAPHY
bull Duncan L Heathcoat J Djurdjev O amp Levin A (2001) Screening for renal disease using serum creatinine who are we missing Nephrology Dialysis and Transplant 16(5) 1042-1046
bull Dunkler D Gao P Lee S F Heinz G Clase C M Tobe S Oberbauer R (2015 August 7) Risk prediction for early CKD in type 2 diabetes Retrieved from Clinical Journal of the American Society of Nephrology httpcjasnasnjournalsorgcontent1081371fullsid=61422554-a5f1-41ac-b696-dcd3b12bd268
bull Fatehi P amp Chi-yuan H (September 15 2016) Diagnostic approach to the patient with newly identified chronic kidney disease (G C Curhan amp A M Sheridan Eds) Retrieved May 7 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsdiagnostic-approach-to-the-patient-with-newly-identified-chronic-kidney-disease
bull Fink J e (2009) Chronic Kidney Disease as an Under-Recognized Threat to Patient Safety American journal of kidney diseases the official journal of the National Kidney Foundation 53(4) 681-688
bull Gaffo A L amp Saag K G (2008 Nov) Management of hyperuricemia and gout in CKD doihttpdxdoiorg101053jajkd200807035
bull Hebert L A amp Parikh S V (2014 June 18) Differential diagnosis and evaluation of glomerular disease (R J Glassock amp A Q Lam Eds) Retrieved May 7 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsdifferential-diagnosis-and-evaluation-of-glomerular-disease
bull Inker L Perrone R D Sterns R H amp Forman J P (2017 March 7) Assessment of kidney function Retrieved from UpToDate httpswww-uptodate-comproxywichitaeducontentsassessment-of-kidney-functionsource=search_resultampsearch=creatinineampselectedTitle=1~150
BIBLIOGRAPHY
bull James P A Ortiz E amp Et Al (2014) Evidence based guideline for the management of high blood pressure in adults (JNC) JAMA 311(5) 507-520
bull Kidney Disease Improving Global Outcomes (KDIGO) CKD Work Group (2013 January) KDIGO 2012 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease Retrieved from Kidney International Supplement httpwwwkidney-internationalorg
bull Kunz R Friedrich C Wolbers M amp Mann J F (2008) Meta-analysis effect of monotherapy and combination therapy with inhibitors of the renin angiotensin system on proteinuria in renal disease Annals of Internal Medicine 148(1) 30-48
bull Levey A Stevens L A Schmid C H Castro A F Feldman H I Kusek J W Coresh J (2009) A new equation to estimate glomerular filtration rate Annals of Internal Medicine 150(9) 604-612
bull Levin A Bakris G L Molitch M Smulders M M Williams L A amp Andress D L (2007 Jan) Prevalence of abnormal serum vitamin D PTH calcium and phosphorus in patients with chronic kidney disease results of the study to evaluate early kidney disease Kidney International 71(1) 31-38 Retrieved from PubMED
bull Mahajan A Simoni J Sheather S Broglio K Rajab M amp Wesson D (2010) Daily oral sodium bicarbonate preserves glomerular filtration rate by slowing its decline in early hypertensive nephropathy Kidney International (78_ 303-309
bull Mann J Schmieder R E amp McQueen M (2008) Renal outcomes with telmisartan ramipril or both in people at high vascular risk (the ONTARGET study) a multicentre randomised doubleblind ocntrolled trial Lancet 372(9638) 547-533
BIBLIOGRAPHY
bull Matovinović M S (2009) Pathophysiology and classification of kidney disease Retrieved from The Journal of the International Federation of Clinical Chemistry and Laboratory Medicine httpwwwifccorgifccfilesdocs20010902pdf
bull Moe S Drueke T Lameire N amp Eknoyan G (2007 Jan) Chronic kidney disease-mineral-bone disorder a new paradigmdoi101053jackd200610005
bull Murtagh F E Marsh J E Donohoe P Ekbal N J Sheerin N S amp Harris F E (2007 July) Dialysis or not A comparative survival study of patients over 75 years with chronic kidney disease stage 5 Retrieved from Nephrology Dialysis and Transplant 22(7) httpswwwncbinlmnihgovpubmed17412702
bull National Kidney Foundation (2002) KDOQI clinical practice guidelines for chronic kidney disease evaluation classification andstratification American Journal of Kidney Disease S1-S266
bull National Kidney Foundation (2014 November 5) Fact Sheets Retrieved from httpwwwkidneyorgnewsnewsroomfactsheetsFastFacts
bull Pal S (2012 June 2) Trends in chronic kidney disease Retrieved from US Pharmacist (37)6 httpswwwuspharmacistcomarticletrends-in-chronic-kidney-disease
bull Qunibi W amp Henrich W L (2017 Jan 19) Overview of chronic kidney disease-mineral and bone disorder (J Berns amp A M Sheridan Eds) Retrieved from UpToDate httpswww-uptodate-comoverview-of-chronic-kidney-disease-mineral-and-bone-disorder-ckd-mbd
bull Rosenberg M (2016 Feb 24) Overview of the management of chronic kidney disease in adults (G C Curhan amp A M Sheridan Eds) Retrieved from UpToDate UpToDate httpswww-uptodate-comproxywichitaeducontentsoverview-of-the-management-of-chronic-kidney-disease-in-adults
BIBLIOGRAPHY
bull Szczech L Stewart R C Hsu-Lin S DeLosky R J Astor B C Fox C H Vassalotti J A (2014) Primary care detection of chronic kidney disease in adults with type 2 diabetes The ADD-CKD Study (Awareness Detection and Drug Therapy in type 2 diabetes and chronic kidney disease PLOS doihttpsdoiorg101371journalpone0110535
bull USRDS (2016) Annual data report 2016 Epidemiology of kidney disease in the United States Retrieved from United States Renal Data System httpswwwusrdsorgadraspx
bull Vasudev B amp Vasudev M (2012) A model curriculum for residents rotating in nephrology MedEDPORTAL doihttpdoiorg1015766mep_2374-82658288
bull Wei L MacDonald T M Jennings C Sheng X amp Flynn R W (2013) Estimated GFR reporting is associated with decreased nonsteroidal anti-inflammatory drug prescribing and increased renal function Kidney International (84)1 174-178
chronic kidney disease in primary care
CKD as a Public Health Issue
Slide Number 3
Costs of CKD in 2013 dollarsUSRDS report
Steps to CKD Patient Care
Renal anatomy and physiology
Definition of Chronic Kidney Disease
CKD Risk Factors
Gaps in CKD Diagnosis
Slide Number 10
Steps to CKD Patient Care
creatinine
Glomerular filtration rate
Slide Number 14
Slide Number 15
Use These Equations Cautiously if at all in hellip
lab albumin creatinine ratio
The New CKD Categories
Steps to CKD Patient Care
Slide Number 20
Kidney Involvement in Systemic Diseases
Slide Number 22
Slide Number 23
DysmorphicRenal Hematuria
Slide Number 25
If you have albuminuria or hematuria-order the following labs
Prevalence of Abnormalities of Mineral Metabolism PTH in CKD
Managing CKD-MBD complications
CKD-MBD Testing
Anemia Becomes More Common as Kidney Function Declines
Detect and Manage CKD Complications
Complications-metabolic acidosis
Complications-vascular calcification
Hyperkalemia management
Hyperuricemia levels amp CKD
CKD monitoring levels 345
Slide Number 59
When to Refer to a Nephrologist
When to Refer
Steps to CKD Patient Care
Kidney transplantation
Starting Dialysis in the ElderlyhellipOr Not
Ckd management
Case 1
Slide Number 67
Lab results
Slide Number 69
Hypertensive nephropathy with proteinuria
Slide Number 71
Case 2
Slide Number 73
Management of CKD in Diabetes
Case 3
Case 3
Systemic Lupus Erythematosus (SLE)
SLE ndash Lupus Nephritis
Case 5
Case 5
Slide Number 81
Slide Number 82
Case study
Slide Number 84
CXR ndash Hilar Lymphadenopathy
Whats needed next
Slide Number 87
newly dx ckd
Slide Number 89
Bibliography
bibliography
bibliography
bibliography
bibliography
Stage 12
Stage 3
Stage 4
Stage 5
Hb le10 gdL
52
56
11
272
Hb gt10-le12 gdL
216
359
426
483
Hb le12 gdL
267
416
536
755
Stage 12
Stage 3
Stage 4
Stage 5
CKD AS A PUBLIC HEALTH ISSUEbull 26 million American affectedbull Prevalence is 1 out of 9 peoplebull 28 of Medicare budget in 2013 up from 69 in 1993bull $gt50 billion in 2016bull Increases risk for all-cause mortality CV mortality kidney failure (ESRD) and
other adverse outcomesbull 6 fold increase in mortality rate with DM + CKDbull Disproportionately affects African Americans and Hispanics
1 NKF Fact Sheets httpwwwkidneyorgnewsnewsroomfactsheetsFastFacts Accessed Nov 5 20142 USRDS wwwusrdsorg Accessed Nov 5 20143 Coresh et al JAMA 2007 2982038-2047
Table 63 Adjusted survival () by treatment modality and incident cohort year (year of ESRD onset) Dialysis
USRDS 2016 Annual Data Report Vol 2 ESRD Ch 6
3
Data Source Reference Tables I1_adj-I36_adj Adjusted survival probabilities from day one in the ESRD population Reference population incident ESRD patients 2011 Adjusted for age sex race Hispanic ethnicity and primary diagnosis Abbreviation ESRD end-stage renal disease
bull Structural or functional abnormalities of the kidneys with our without decreased GFR manifest by either
bull Pathological abnormalities
bull Markers of kidney damage including abnormalities in the composition of the blood or urine or in imaging tests
bull GFR lt 60 mlmin173 m2 for gt 3 months with or without kidney damage as defined above
(Kidney Disease Improving Global Outcomes (KDIGO) CKD Work Group 2013)
CKD RISK FACTORS
Modifiablebull Diabetesbull Hypertensionbull History of AKIbull Frequent NSAID use
bull Obesity
bull Hyperuricemia
bull Smoking
bull Sedentary lifestyle
bull Dietary Protein Intake
Non-modifiablebull Family history of kidney disease diabetes or
hypertension
bull Age 60 or older (GFR declines normally with age)
bull RaceUS ethnic minority status
Partial listAKI acute kidney injury (Kidney Disease Improving Global Outcomes (KDIGO) CKD Work Group 2013)
GAPS IN CKD DIAGNOSIS
Szczech Lynda A et al Primary Care Detection of Chronic Kidney Disease in Adults with Type-2 Diabetes The ADD-CKD Study (Awareness Detection and Drug Therapy in Type-2 Diabetes and Chronic Kidney Disease) PLOS One - In press (2014)
0
10
20
30
40
50
60
Not Appropriately Tested Appropriately tested - no diagnosis Appropriately tested - accurate diagnosis
CKD Screening in Primary Care( of patients)
of Patients
Improved Diagnosishellip
Studies demonstrate that clinician behavior changes when CKD diagnosis improves Significant improvements realized in1-3
bull Increased urinary albumin testingbull Increased appropriate use of ACEi or ARBbull Avoidance of NSAIDs prescribing among patients
with low eGFRbull Appropriate nephrology consultation
1 Wei L et al Kidney Int 201384174-1782 Chan M et al Am J Med 20071201063-10703 Fink J et al Am J Kidney Dis 200953681-668
STEPS TO CKD PATIENT CARE
1 CKD definition and risks2 Assess GFR albuminuria (knowing the labs)3 Determine etiology4 Slow progression5 Assess for associated complications6 Discuss dialysistransplantation
CREATININEbull Creatinine is derived from the metabolism of creatine in skeletal
muscle and from dietary meat intake
creatinine secretion by the renal tubules + creatine intake (ie diet)+ creatinine pool size (ie muscle mass) all remain constant
bull GFR is equal to the sum of the filtration rates in all of the functioning nephrons
bull Glomeruli filter 180Lday (125mLmin) of plasma
bull Normal GFR depends on age sex body size and is approximately 130mLmin for men and 120mLmin for womenmdashwith considerable variation
bull CKD-EPI equation (estimated GFR in mLmin173m2) is most accurate
Age Gender RaceSCr
(mgdL) eGFR (mLmin173 m2)
20 M B 13 91
20 M W 13 75
55 M W 13 61
20 F W 13 56
55 F B 13 55
50 F W 13 46
B = black W = all ethnic groups other than blackWith evidence of kidney damage
(Duncan Heathcoat Djurdjev amp Levin 2001)(National Kidney Foundation 2002)
or lt 15 mLmin173m2
(Levey et al 2009)
True GFR could be gt 70 mLmin173m2
The ldquoerdquo in eGFR Stands for ldquoEstimatedrdquohellip
USE THESE EQUATIONS CAUTIOUSLY IF AT ALL IN hellip
bull Patients who haveare
bull Poor nutritionloss of muscle mass
bull Amputation
bull Chronic illness
bull Not African American or Caucasian
bull Changing serum creatinine
bull Obese
bull Very elderly young
(National Kidney Foundation 2014)
LAB ALBUMIN CREATININE RATIO
bull Urinary albumin-to-creatinine ratio (ACR) is calculated by dividing albumin concentration in milligrams by creatinine concentration in grams
bull Creatinine assists in adjusting albumin levels for varying urine concentrations which allows for more accurate results versus albumin alone
bull Spot urine albumin-to-creatinine ratio for quantification of proteinuria
bull New guidelines classify albuminuria as mild moderately or severely increased
bull First morning void preferable
bull 24hr urine test rarely necessary
THE NEW CKD CATEGORIES
STEPS TO CKD PATIENT CARE
1 CKD definition and risks2 Assess GFR albuminuria3 Determine etiology- what is going on here4 Slow progression5 Assess for associated complications6 Discuss dialysistransplantation
(Pal 2012)
KIDNEY INVOLVEMENT IN SYSTEMIC DISEASES
Hypertension
DiabetesAmyloidosis
Sickle cell diseases
Immune complex GN
Illicit drugs ndash cocaine heroin
Cholesterol emboli
HIV
Allergic reactions- drugsinterstitial nephritis
Hemolytic Uremic syndrome
Lupus
Systemic vasculitis
Liver FailureCongestive heart Failure
Image retrieved on 05 October 2010 from httpenwikipediaorgwikiFileGray1129pngThis image is under the public domain and not copyrightable in the US as per Bridgeman Art Library v Corel Corp
(Vasudev amp Vasudev 2012)
New CKD
Obtain ultrasound UA
microscopy albumincr ratio
Ultrasound shows
obstruction
bull Yes Relieve obstruction
bull No Is there albuminuria or glomerular bleeding (eval for glomerulo-nephritis
Fatehi amp Chi-yuan 2016
If red cells have their typical shape and color this indicates extra glomerular hematuria
Examples kidney stone disease UTI cystitis bleeding from collecting duct ureters bladder or urethra
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileReactive_lymphJPGCreative Commons License associated httpcreativecommonsorglicensesby-sa30deeden
(Vasudev amp Vasudev 2012)
DYSMORPHICRENAL HEMATURIA
bull This hematuria is characterized by bull a great variation in the size of the cells and by a high
percentage of dysmorphocytosiscasts (gt20)
bull Hematuria is usually related to glomerular bleeding bull It is typically accompanied by variable levels of albumuniuria
(Vasudev amp Vasudev 2012)
Urinary Cast Formation
Urine Microscopy can be helpful in work up of chronic kidney disease
In GNrsquos the red blood cells leak from the glomerulus into the tubules As they traverse through the tubules they can form cylindrical casts calledRBC casts
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileRedbloodcellsjpgThis image is a work of the National Institutes of Health part of the United States Department of Health and Human Services As a work of the US federal government the image is in the public domain
(Vasudev amp Vasudev 2012)
IF YOU HAVE ALBUMINURIA OR HEMATURIA-ORDER THE FOLLOWING LABS
Tests of autoimmunity Hepatitis serologies gt40 years- paraproteinassessment
ANA Hepatitis B serology (HBsAG)
Serum protein electrophoresis (SPEP)
RFanti-ccp Hepatitis C serology(HCV antibody)
Urine protein electrophoresis (UPEP)
Complement C3 C4
ANCANational Kidney Disease Education Program 2014 NIH
UPTODATE LAB RECOMENDATIONS
bull Lab to order cbc cmp urine albumincr ratio urine microscopy
bull Nephrotic pattern (protein gt35gday) ANA anti DS DNA C3 and C4 antibodies HIV HBV HCV serumurine immunofixation (amyloidosis) free light chain analysis (light chain deposition disease)
bull Nephritic pattern (red cells white cells casts variable protein) C3 C4 ANA dsDNA antineutrophil cytoplasmic antibody (ANCA) titers a streptozyme test HBV and HCV serologies HIV and in some cases blood cultures anti-glomerular basement membrane (GBM) antibodies and cryoglobulins
bull Renal biopsy(Hebert amp Parikh 2014)
EVALUATION OF NEW CKDNO OBSTRUCTION
NO EVIDENCE OF GLOMERULAR BLEEDING
High risk for multmyeloma (gt40
no nsaids no contrast
SPEP UPEP with immunofixation serum free light
chains
Evaluation depends on UA
Sterile pyuria
Eval for interstitial nephritis
Normal urinalysis
High risk for renovascular
disease
Eval for renovascular
disease
Follow serum creatinine-does it
remain stable(Fatehi amp Chi-yuan 2016)
POSSIBLE INVESTIGATIONShellip
Acute interstitial nephritisbull Drugs are the most common cause of AIN
DIABETIC NEPHROPATHY 1 CAUSE OF CKDbull Clinical syndromebull Albuminuria gt30 mg 24 hrsbull Proteinuria gt500 mg24 hrsbull Hypertension developsbull Progressive increase in proteinuriabull Progressive decline in glomerular filtration rate
bull Chronic kidney disease should be attributed to diabetic nephropathies in most patients with diabetes if albuminuria and diabetic retinopathy are both present other causes of CKD should be entertained if diabetic retinopathy is absent (KDIGO 2007)
DIABETIC NEPHROPATHY MORTALITY
bull After 40 yrs of DM
bull 10 alive if proteinuria is present
bull 70 alive if proteinuria is absent
bull Heart Disease is 15 times higher risk in those with proteinuria
bull Proteinuria = death in this population
Dunkler et al 2015
GOALS OF CARE IN CKD GLUCOSE CONTROL
bull Target HbA1c ~70 (lt695 greatest chance of reducing albuminuria)bull Can be extended above 70 with comorbidities or limited life expectancy and
risk of hypoglycemiabull Risk of hypoglycemia increases as kidney function becomes impairedbull Declining kidney function may necessitate changes to diabetes medications and
bull Just having HTN can cause proteinuriabull Usually 1-2 gms of protein a daybull Treat them like a diabetic with ACEI or ARBS and tight blood
pressure controlbull JNC-8 goal lt14090 for ptrsquos with CKDbull National kidney foundation lt14090 if ckd and no proteinuria
lt13080 if proteinuria present
(James Ortiz amp Et Al 2014)
TREATING HYPERTENSIONPROTEINURIA ACEI ORARBbull Riskbenefit should be carefully assessed in the elderly and medically fragilebull Check labs after initiation
bull If less than 30 SCr increase continue and monitorbull If more than 30 SCr increase stop ACEi and evaluate for renal artery stenosis
bull Continue until contraindication arises no absolute eGFR cutoffbull Better proteinuria suppression with low Na diet and diureticsbull Avoid volume depletionbull Avoid ACEi and ARB in combination12
bull Risk of adverse events (impaired kidney function hyperkalemia)
(Kunz Friedrich Wolbers amp Mann 2008)(Mann Schmieder amp McQueen 2008)
bull In adults gt50 yrs statin when eGFR ge 60 mlmin173m2 statin or statinezetimibe combination when eGFR lt 60 mlmin173m2
bull In adults lt 50 yrs statin if history of known CAD MI DM strokebull Aspirin is indicated for secondary but not primary prevention
Kidney Disease Improving Global Outcomes (KDIGO) CKD Work Group Kidney Int Suppls 201331-150
STATINS-RENOPROTECTIVECONTROVERSY
bull HMG-CoA reductase inhibitors (statins) in high doses can cause proteinuria
bull Possibly associated with less inflammation endothelial dysfunction and scarring in the kidney because they also block inflammatory cytokines
bull Use statins for CV disease not to treat proteinuria
(Afzali and Goldsmith 2016)
MEDICINE CAUTION
bull Hold metformin when gfr lt35 mlmin
bull GFR lt50 mlmin should alert to check all doses of meds
bull No bisphosphanates lt35 mlmin
bull No NSAIDScox 2 inhibitors lt60 mlmin
bull Atenolol ndashrenal excretion
bull BACTRIM A lot of AKI
MEDICINE CAUTION
bull Lovenox-use subcut heparinbull Apixibanbull Dabigatranbull Rivaroxibanbull Lithiumbull GABAPENTIN (ckd 4 max 300mg qd ckd 5 max 300mg qod)
STEPS TO CKD PATIENT CARE
1 CKD definition and risks2 Assess GFR albuminuria3 Determine etiology4 Assess for evidence of progression5 Assess for associated complications6 Discuss dialysistransplantation
CKD-CVD-DIABETES LINK CKD IS A DISEASE MULTIPLIER
National kidney foundation 2014
KDIGO 2017
CKD-MINERAL BONE DISORDERS
bull As kidneys fail they
bull Stop activating calcitriol (the active form of Vit D)mdashcausing calcium imbalance
bull Do not remove phosphorus from bloodmdashleading to phosphorus retention
bull The extra phosphorus pulls calcium out of bones causing them to weaken
bull High phosphorus stimulates PTH release
bull These changes (plus others) cause the start of secondary hyperparathyroidism
bull Labs
bull eGFR
bull Calcium
bull Phos
bull Vit D
bull iPTH
(Qunibi amp Henrich 2017)
PREVALENCE OF ABNORMALITIES OF MINERAL METABOLISM PTH IN CKD
bull Progression of disease ndash declining eGFR increasing proteinuria
bull Degree of proteinuria nephrotic syndrome gt 05-10 gd on ACEi or ARB therapy
bull Etiology of CKD not certain
bull Need help with disease management
bull Indications for kidney biopsy
Rosenberg 2016
WHEN TO REFER
STEPS TO CKD PATIENT CARE
1 CKD definition and risks2 Assess GFR albuminuria3 Determine etiology4 Assess for evidence of progression5 Assess for associated complications6 Discuss dialysistransplantation
KIDNEY TRANSPLANTATION
bull Treatment of choice for ESRDbull Improves quality of lifebull Waiting list time varies-3-5 yearsbull 3 year survival rate after transplantation is 83-94bull Increased risk of cancer
STARTING DIALYSIS IN THE ELDERLYhellipOR NOT
bull Among patients gt 75 yrs with stage 5 CKD who chose to NOT start dialysisbull Overall more likely to die over next 1-2 years bull But if they had ischemic heart disease or other significant comorbidity NO
DIFFERENCE in survival
bull Active disease management and supportive care may be appropriate without starting dialysis in the ill elderly
bull Palliative care does not mean ldquono carerdquo
bull Must have end-of-life discussions
(Murtagh et al 2007)
CKD MANAGEMENTbull Diagnose cause and treat underlying conditionbull Stage per guidelinesbull Slow progression of kidney disease (ACE inhibitors)bull Monitor for complicationsmdashvolume overload hyperkalemia metabolic acidosis
hyperphosphatemia anorexia fatigue htn bone diseasebull Labs cmp cbc phos Vit D 25OH iPTH urine microscopy uric acid urine
proteincr ratio-frequency based off heat map Get sono at least oncebull Vaccinate influenza hep B pneumococcalbull Eval ASCVD risk-likely needs statinbull Possible dexa (donrsquot give bisphosphonates if GFRlt35 let specialist manage)bull Refer to nephrology when eGFR is lt30 (sometimes if higher risk-refer earlier)
CASE 1
bull 55 year old man with past medical history of headaches presents to your office for his first time visit to a PCP in over 30 years
bull He has no past history of being admitted to the hospital and he does not take any OTC medsNSAIDsherbal meds He has no history of ETOH abuse smoking or drug use
bull Vitals BP 180100 mmHg pulse 80 R 18
bull Exam No JVD S1S2 regular PMI shifted to the left no gallop no abdominal bruit pulses bilaterally equal and regular no leg edema
bull What would you order
bull EKG cbc cmp ua urine proteincr ratio lipid
LAB RESULTS
bull Labs reveal a creatinine of 22 mgdL eGFR 33 Urine shows no blood or casts Urineprotein ratio shows 1 gm protein24 hrs EKG shows LVH
bull Next step in workupbull Renal ultrasound 1st then SPEP UPEP with immunofixation serum free light chains
bull Additional labs neg Renal ultrasound shows that both kidneys are slightly reduced in size and are mildly echogenic with no mass or hydronephrosis
bull What is your diagnosis
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileMain_complications_of_persistent_high_blood_pressurepngCreative Commons License associated httpcreativecommonsorglicensesby-sa30
bull 3 months Howevermdashwe have evidence of structural abnormalities Could potentially stage at G3b A3 (red on the heat map)
bull Goal blood pressure
bull JNC 8 14090 NKF 13080
bull Additional lab needed for progression monitoring
bull Cbc renal panel phos Vit D iPTH uric acid urine micro (we already have the renal sono and urine proteincr ratio and lipid)
Selective renal angiography (left lower renal artery) after successful percutaneous balloon dilatation of the stenotic lesionFibromuscular dysplasia in an accessory renal artery causing renovascular hypertension
Secondary Hypertension
Images retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileRenal_FMD2jpg and httpcommonswikimediaorgwikiFileRenal_FMDjpgCreative Commons License associated httpcreativecommonsorglicensesby20deeden (both images)
CASE 2bull OS is a 64year old Hispanic female in for DM check She has had DM for 15+ years and is currently
taking metformin 1000mg bid Lisinopril 10mg a day atorvastatin 40mg a day Labs today showed the following
bull Hgba1c 86 cmp eGFR 50 lipid WNL proteincr ratio 650mg These results are similar to her last visit
bull Upon further hx-you find that she had a recent eye exam and has mild nonproliferaive retinopathy She does not have neuropathy or other ss
bull What further workup do you need
bull Renal sonogram urine micro iPTH vit D (25 OH) phos uric acid
bull Dx stage
bull G3a A3
bull What further treatment do you need
bull Improve glycemic control Increase Lisinopril to 20mg with a goal of 40mg Avoid NSAIDs or other nephrotoxic agents make sure meds are renally dosed monitor 3xyear nephro referral
MANAGEMENT OF CKD IN DIABETESeGFR Recommended
All patients
Yearly measurement of creatinine urinary albumin excretion potassium
45-60 Referral to a nephrologist if possibility for nondiabetickidney disease existsConsider dose adjustment of medicationsMonitor eGFR every 6 monthsMonitor electrolytes bicarbonate hemoglobin calcium phosphorus parathyroid hormone at least yearly
Assure vitamin D sufficiencyConsider bone density testingReferral for dietary counselling
American Diabetes Association Standards of Medical Care in Diabetes Microvascular complications and foot care Diabetes Care 2017 40 (Suppl 1) S88-S98
CASE 3
bull 19 year old African American woman presents to your clinic with complaints of fatigue joint pains a new rash on her face oral ulcer
bull On exam BP 15080 P 88 Afebrile 96 O2 sats on RAbull GEN No respiratory distress at restbull HEENT painless oral ulcer flat rash over malar eminences sparing the nasolabial fold pallor +bull Lungs CTAbull CVS S1S2 regularbull Abdomen soft NTbull Ext left elbow joint and bilateral wrist joints are swollen and tender
bull What would you orderbull CBC CMP ua urine microscopy (microalbumin or urine proteincr ratio) ANA esr RF anti-ccp uric acid TSH
CASE 3
bull Working dx fatigue oral ulcer joint pain
bull Basic Labs Na 135 K 55 Bicarb 18 BUN 50 Cr 35 eGFR 22 Ca 90 ANA + titer 1640
bull UA 3+ blood 3+ protein RBC casts +
bull Given these results what is the most likely diagnosis
bull What would you do
SYSTEMIC LUPUS ERYTHEMATOSUS (SLE)
bull SLE multisystemic disease Etiology unknown
bull Production of autoantibodies and immune complexes formation
bull There is renal involvement in the great majority of patients with SLE at some time of the evolution 66-90
SLE ndash LUPUS NEPHRITIS
bull Race SLE is more commonsevere in African americans than Caucasiansbull
bull Gender female-to-male ratio of 91
bull Age Most patients develop lupus nephritis early in their disease course SLE is more common among women in the third decade of life and lupus nephritis occurs in patients aged 20-40 years
bull Kidney Biopsy For staging lupus nephritis (Class 1-5)
CASE 5bull A 80 year old man who has not seen a PCP in many years
presents to your clinic for weakness for the past few months On further questioning he tells you that his bones also have been hurting lately and he has developed leg swelling in the past month or so
bull On exam bull BP 16090 P 88 Afebrilebull GEN Thin built manbull HEENT pallor presentbull Lungs clearbull CVS S1S2 regular no rub or gallopbull Abdomen soft NTbull Ext 2 + edema
CASE 5
bull Differentials
bull CHF MI Cancer arthritis
bull Labs
bull CBC CMP urine microscopy urine proteincr ratio ESR TSH EKG BNP pa and lat CXR
bull LABS Urine dipstick negative for protein or blood
bull Basic chem bull Na 136 (135-145) K 51 (35-55) Chloride 108 (96-106) Bicarb 25
Given this presentation and the labs (low anion gap and elevated calcium anemia kidney failure) what will you think of What will you order next
Serum and urine protein electrophoresis
Intratubular refractile casts with surrounding syncytial giant cell reaction with chronic tubulointerstitial nephritis and fibrosis characteristic of myeloma cast nephropathy
Kidney Biopsy
CASE STUDYbull A 35 year old African American woman was seen in the clinic for
chronic cough and dyspnea on exertion She gave history of vague symptoms of fatigue and weight loss of 20 Ibs over the last six months
bull List some differentialsbull TB sarcoid lupus thyroid problems PEbull What would you orderbull PPD cbc cmp UA TSH ANA pa and lat cxr
bull Her labs were significant for mildly elevated calcium level and a creatinine of 20 mgdL eGFR 37
bull She had 750 mg of proteinuriaday
bull PPD neg ANA neg TSH and other labs WNL
bull Assuming this is present more than 3 monthshelliphellipwhat is her ckd stage
bull G3b A3
bull What do we still need
CT scan of chest
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileAnterior_mediastinal_mass_thymomajpgCreative Commons License associated httpcreativecommonsorglicensesby20deeden
CXR ndash HILAR LYMPHADENOPATHY
WHATS NEEDED NEXT
bull Biopsy of hilar lymphadenopathy or renal biopsy
bull DX sarcoidosis
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileSarcoidosis_signs_and_symptomsjpgThis work is in the public domain in the United States because it is a work of the United States Federal Government under the terms of Title 17 Chapter 1 Section 105 of the US Code
NEWLY DX CKD
bull 1) urinalysis microscopy ultrasound proteincr ratio
bull If obstruction-treat
bull No obstruction
bull Hx critical (consider myeloma if high risk)
bull glomerular bleeding or albumin in urine
bull Yes workup for glomerular causes (ANArf hep B C upep spep ANCA complement C3 C4)
bull No sterile pyruria-consider interstitial nephritis
bull High risk renovascular disease Evaluate renovascular disease
Additional Online Resources for CKD LearningbullNational Kidney Foundation wwwkidneyorgbullUnited States Renal Data Service wwwusrdsorgbullCDCrsquos CKD Surveillance Project
httpnccdcdcgovckdbullNational Kidney Disease Education Program
(NKDEP) httpnkdepnihgov
BIBLIOGRAPHY
bull Afzali B amp Goldsmith D J (2016 June 29) Statins and chronic kidney disease (G C Curhan amp A M Sheridan Eds) Retrieved 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsstatins-and-chronic-kidney-disease
bull American Diabetes Association Standards of Medical Care in Diabetes (2017) Microvascular complications and foot care Diabetes Care 2017 (40) S88-S98
bull American Diabetes Association Standards of Medical Care in Diabetes (2017) Microvascular complications and foot care Diabetes Care 40 (suppl 1) S88-S98
bull Berns J S (2017 Mar 22) Treatment of anemia in nondialysis chronic kidney disease (T A Golper amp A M Sheridan Eds) Retrieved from UpToDate httpswww-uptodate-comproxywichitaeducontentstreatment-of-anemia-in-nondialysis-chronic-kidney-disease
bull Chan M Dall A T Fletcher K E Lu N amp Trivedi H (2007) Outcomes in patients with chronic kidney disease referred late to nephrologists a meta-analysis American Journal of Medicine 120(12) 1063-1070
bull Coresh J Selvin E amp Stevens L A (2007) Prevalence of chronic kidny disease in the United States JAMA 298(17) doi101001jama298172038
bull de Brito-Ashurst I Varagunam M Raftery M amp Yagoob M (2009) Bicarbonate supplementation slows progression of CKD and improves nutritional status Journal of American Society of Nephrology (20) 2075-2084
BIBLIOGRAPHY
bull Duncan L Heathcoat J Djurdjev O amp Levin A (2001) Screening for renal disease using serum creatinine who are we missing Nephrology Dialysis and Transplant 16(5) 1042-1046
bull Dunkler D Gao P Lee S F Heinz G Clase C M Tobe S Oberbauer R (2015 August 7) Risk prediction for early CKD in type 2 diabetes Retrieved from Clinical Journal of the American Society of Nephrology httpcjasnasnjournalsorgcontent1081371fullsid=61422554-a5f1-41ac-b696-dcd3b12bd268
bull Fatehi P amp Chi-yuan H (September 15 2016) Diagnostic approach to the patient with newly identified chronic kidney disease (G C Curhan amp A M Sheridan Eds) Retrieved May 7 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsdiagnostic-approach-to-the-patient-with-newly-identified-chronic-kidney-disease
bull Fink J e (2009) Chronic Kidney Disease as an Under-Recognized Threat to Patient Safety American journal of kidney diseases the official journal of the National Kidney Foundation 53(4) 681-688
bull Gaffo A L amp Saag K G (2008 Nov) Management of hyperuricemia and gout in CKD doihttpdxdoiorg101053jajkd200807035
bull Hebert L A amp Parikh S V (2014 June 18) Differential diagnosis and evaluation of glomerular disease (R J Glassock amp A Q Lam Eds) Retrieved May 7 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsdifferential-diagnosis-and-evaluation-of-glomerular-disease
bull Inker L Perrone R D Sterns R H amp Forman J P (2017 March 7) Assessment of kidney function Retrieved from UpToDate httpswww-uptodate-comproxywichitaeducontentsassessment-of-kidney-functionsource=search_resultampsearch=creatinineampselectedTitle=1~150
BIBLIOGRAPHY
bull James P A Ortiz E amp Et Al (2014) Evidence based guideline for the management of high blood pressure in adults (JNC) JAMA 311(5) 507-520
bull Kidney Disease Improving Global Outcomes (KDIGO) CKD Work Group (2013 January) KDIGO 2012 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease Retrieved from Kidney International Supplement httpwwwkidney-internationalorg
bull Kunz R Friedrich C Wolbers M amp Mann J F (2008) Meta-analysis effect of monotherapy and combination therapy with inhibitors of the renin angiotensin system on proteinuria in renal disease Annals of Internal Medicine 148(1) 30-48
bull Levey A Stevens L A Schmid C H Castro A F Feldman H I Kusek J W Coresh J (2009) A new equation to estimate glomerular filtration rate Annals of Internal Medicine 150(9) 604-612
bull Levin A Bakris G L Molitch M Smulders M M Williams L A amp Andress D L (2007 Jan) Prevalence of abnormal serum vitamin D PTH calcium and phosphorus in patients with chronic kidney disease results of the study to evaluate early kidney disease Kidney International 71(1) 31-38 Retrieved from PubMED
bull Mahajan A Simoni J Sheather S Broglio K Rajab M amp Wesson D (2010) Daily oral sodium bicarbonate preserves glomerular filtration rate by slowing its decline in early hypertensive nephropathy Kidney International (78_ 303-309
bull Mann J Schmieder R E amp McQueen M (2008) Renal outcomes with telmisartan ramipril or both in people at high vascular risk (the ONTARGET study) a multicentre randomised doubleblind ocntrolled trial Lancet 372(9638) 547-533
BIBLIOGRAPHY
bull Matovinović M S (2009) Pathophysiology and classification of kidney disease Retrieved from The Journal of the International Federation of Clinical Chemistry and Laboratory Medicine httpwwwifccorgifccfilesdocs20010902pdf
bull Moe S Drueke T Lameire N amp Eknoyan G (2007 Jan) Chronic kidney disease-mineral-bone disorder a new paradigmdoi101053jackd200610005
bull Murtagh F E Marsh J E Donohoe P Ekbal N J Sheerin N S amp Harris F E (2007 July) Dialysis or not A comparative survival study of patients over 75 years with chronic kidney disease stage 5 Retrieved from Nephrology Dialysis and Transplant 22(7) httpswwwncbinlmnihgovpubmed17412702
bull National Kidney Foundation (2002) KDOQI clinical practice guidelines for chronic kidney disease evaluation classification andstratification American Journal of Kidney Disease S1-S266
bull National Kidney Foundation (2014 November 5) Fact Sheets Retrieved from httpwwwkidneyorgnewsnewsroomfactsheetsFastFacts
bull Pal S (2012 June 2) Trends in chronic kidney disease Retrieved from US Pharmacist (37)6 httpswwwuspharmacistcomarticletrends-in-chronic-kidney-disease
bull Qunibi W amp Henrich W L (2017 Jan 19) Overview of chronic kidney disease-mineral and bone disorder (J Berns amp A M Sheridan Eds) Retrieved from UpToDate httpswww-uptodate-comoverview-of-chronic-kidney-disease-mineral-and-bone-disorder-ckd-mbd
bull Rosenberg M (2016 Feb 24) Overview of the management of chronic kidney disease in adults (G C Curhan amp A M Sheridan Eds) Retrieved from UpToDate UpToDate httpswww-uptodate-comproxywichitaeducontentsoverview-of-the-management-of-chronic-kidney-disease-in-adults
BIBLIOGRAPHY
bull Szczech L Stewart R C Hsu-Lin S DeLosky R J Astor B C Fox C H Vassalotti J A (2014) Primary care detection of chronic kidney disease in adults with type 2 diabetes The ADD-CKD Study (Awareness Detection and Drug Therapy in type 2 diabetes and chronic kidney disease PLOS doihttpsdoiorg101371journalpone0110535
bull USRDS (2016) Annual data report 2016 Epidemiology of kidney disease in the United States Retrieved from United States Renal Data System httpswwwusrdsorgadraspx
bull Vasudev B amp Vasudev M (2012) A model curriculum for residents rotating in nephrology MedEDPORTAL doihttpdoiorg1015766mep_2374-82658288
bull Wei L MacDonald T M Jennings C Sheng X amp Flynn R W (2013) Estimated GFR reporting is associated with decreased nonsteroidal anti-inflammatory drug prescribing and increased renal function Kidney International (84)1 174-178
chronic kidney disease in primary care
CKD as a Public Health Issue
Slide Number 3
Costs of CKD in 2013 dollarsUSRDS report
Steps to CKD Patient Care
Renal anatomy and physiology
Definition of Chronic Kidney Disease
CKD Risk Factors
Gaps in CKD Diagnosis
Slide Number 10
Steps to CKD Patient Care
creatinine
Glomerular filtration rate
Slide Number 14
Slide Number 15
Use These Equations Cautiously if at all in hellip
lab albumin creatinine ratio
The New CKD Categories
Steps to CKD Patient Care
Slide Number 20
Kidney Involvement in Systemic Diseases
Slide Number 22
Slide Number 23
DysmorphicRenal Hematuria
Slide Number 25
If you have albuminuria or hematuria-order the following labs
Prevalence of Abnormalities of Mineral Metabolism PTH in CKD
Managing CKD-MBD complications
CKD-MBD Testing
Anemia Becomes More Common as Kidney Function Declines
Detect and Manage CKD Complications
Complications-metabolic acidosis
Complications-vascular calcification
Hyperkalemia management
Hyperuricemia levels amp CKD
CKD monitoring levels 345
Slide Number 59
When to Refer to a Nephrologist
When to Refer
Steps to CKD Patient Care
Kidney transplantation
Starting Dialysis in the ElderlyhellipOr Not
Ckd management
Case 1
Slide Number 67
Lab results
Slide Number 69
Hypertensive nephropathy with proteinuria
Slide Number 71
Case 2
Slide Number 73
Management of CKD in Diabetes
Case 3
Case 3
Systemic Lupus Erythematosus (SLE)
SLE ndash Lupus Nephritis
Case 5
Case 5
Slide Number 81
Slide Number 82
Case study
Slide Number 84
CXR ndash Hilar Lymphadenopathy
Whats needed next
Slide Number 87
newly dx ckd
Slide Number 89
Bibliography
bibliography
bibliography
bibliography
bibliography
Stage 12
Stage 3
Stage 4
Stage 5
Hb le10 gdL
52
56
11
272
Hb gt10-le12 gdL
216
359
426
483
Hb le12 gdL
267
416
536
755
Stage 12
Stage 3
Stage 4
Stage 5
Table 63 Adjusted survival () by treatment modality and incident cohort year (year of ESRD onset) Dialysis
USRDS 2016 Annual Data Report Vol 2 ESRD Ch 6
3
Data Source Reference Tables I1_adj-I36_adj Adjusted survival probabilities from day one in the ESRD population Reference population incident ESRD patients 2011 Adjusted for age sex race Hispanic ethnicity and primary diagnosis Abbreviation ESRD end-stage renal disease
bull Structural or functional abnormalities of the kidneys with our without decreased GFR manifest by either
bull Pathological abnormalities
bull Markers of kidney damage including abnormalities in the composition of the blood or urine or in imaging tests
bull GFR lt 60 mlmin173 m2 for gt 3 months with or without kidney damage as defined above
(Kidney Disease Improving Global Outcomes (KDIGO) CKD Work Group 2013)
CKD RISK FACTORS
Modifiablebull Diabetesbull Hypertensionbull History of AKIbull Frequent NSAID use
bull Obesity
bull Hyperuricemia
bull Smoking
bull Sedentary lifestyle
bull Dietary Protein Intake
Non-modifiablebull Family history of kidney disease diabetes or
hypertension
bull Age 60 or older (GFR declines normally with age)
bull RaceUS ethnic minority status
Partial listAKI acute kidney injury (Kidney Disease Improving Global Outcomes (KDIGO) CKD Work Group 2013)
GAPS IN CKD DIAGNOSIS
Szczech Lynda A et al Primary Care Detection of Chronic Kidney Disease in Adults with Type-2 Diabetes The ADD-CKD Study (Awareness Detection and Drug Therapy in Type-2 Diabetes and Chronic Kidney Disease) PLOS One - In press (2014)
0
10
20
30
40
50
60
Not Appropriately Tested Appropriately tested - no diagnosis Appropriately tested - accurate diagnosis
CKD Screening in Primary Care( of patients)
of Patients
Improved Diagnosishellip
Studies demonstrate that clinician behavior changes when CKD diagnosis improves Significant improvements realized in1-3
bull Increased urinary albumin testingbull Increased appropriate use of ACEi or ARBbull Avoidance of NSAIDs prescribing among patients
with low eGFRbull Appropriate nephrology consultation
1 Wei L et al Kidney Int 201384174-1782 Chan M et al Am J Med 20071201063-10703 Fink J et al Am J Kidney Dis 200953681-668
STEPS TO CKD PATIENT CARE
1 CKD definition and risks2 Assess GFR albuminuria (knowing the labs)3 Determine etiology4 Slow progression5 Assess for associated complications6 Discuss dialysistransplantation
CREATININEbull Creatinine is derived from the metabolism of creatine in skeletal
muscle and from dietary meat intake
creatinine secretion by the renal tubules + creatine intake (ie diet)+ creatinine pool size (ie muscle mass) all remain constant
bull GFR is equal to the sum of the filtration rates in all of the functioning nephrons
bull Glomeruli filter 180Lday (125mLmin) of plasma
bull Normal GFR depends on age sex body size and is approximately 130mLmin for men and 120mLmin for womenmdashwith considerable variation
bull CKD-EPI equation (estimated GFR in mLmin173m2) is most accurate
Age Gender RaceSCr
(mgdL) eGFR (mLmin173 m2)
20 M B 13 91
20 M W 13 75
55 M W 13 61
20 F W 13 56
55 F B 13 55
50 F W 13 46
B = black W = all ethnic groups other than blackWith evidence of kidney damage
(Duncan Heathcoat Djurdjev amp Levin 2001)(National Kidney Foundation 2002)
or lt 15 mLmin173m2
(Levey et al 2009)
True GFR could be gt 70 mLmin173m2
The ldquoerdquo in eGFR Stands for ldquoEstimatedrdquohellip
USE THESE EQUATIONS CAUTIOUSLY IF AT ALL IN hellip
bull Patients who haveare
bull Poor nutritionloss of muscle mass
bull Amputation
bull Chronic illness
bull Not African American or Caucasian
bull Changing serum creatinine
bull Obese
bull Very elderly young
(National Kidney Foundation 2014)
LAB ALBUMIN CREATININE RATIO
bull Urinary albumin-to-creatinine ratio (ACR) is calculated by dividing albumin concentration in milligrams by creatinine concentration in grams
bull Creatinine assists in adjusting albumin levels for varying urine concentrations which allows for more accurate results versus albumin alone
bull Spot urine albumin-to-creatinine ratio for quantification of proteinuria
bull New guidelines classify albuminuria as mild moderately or severely increased
bull First morning void preferable
bull 24hr urine test rarely necessary
THE NEW CKD CATEGORIES
STEPS TO CKD PATIENT CARE
1 CKD definition and risks2 Assess GFR albuminuria3 Determine etiology- what is going on here4 Slow progression5 Assess for associated complications6 Discuss dialysistransplantation
(Pal 2012)
KIDNEY INVOLVEMENT IN SYSTEMIC DISEASES
Hypertension
DiabetesAmyloidosis
Sickle cell diseases
Immune complex GN
Illicit drugs ndash cocaine heroin
Cholesterol emboli
HIV
Allergic reactions- drugsinterstitial nephritis
Hemolytic Uremic syndrome
Lupus
Systemic vasculitis
Liver FailureCongestive heart Failure
Image retrieved on 05 October 2010 from httpenwikipediaorgwikiFileGray1129pngThis image is under the public domain and not copyrightable in the US as per Bridgeman Art Library v Corel Corp
(Vasudev amp Vasudev 2012)
New CKD
Obtain ultrasound UA
microscopy albumincr ratio
Ultrasound shows
obstruction
bull Yes Relieve obstruction
bull No Is there albuminuria or glomerular bleeding (eval for glomerulo-nephritis
Fatehi amp Chi-yuan 2016
If red cells have their typical shape and color this indicates extra glomerular hematuria
Examples kidney stone disease UTI cystitis bleeding from collecting duct ureters bladder or urethra
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileReactive_lymphJPGCreative Commons License associated httpcreativecommonsorglicensesby-sa30deeden
(Vasudev amp Vasudev 2012)
DYSMORPHICRENAL HEMATURIA
bull This hematuria is characterized by bull a great variation in the size of the cells and by a high
percentage of dysmorphocytosiscasts (gt20)
bull Hematuria is usually related to glomerular bleeding bull It is typically accompanied by variable levels of albumuniuria
(Vasudev amp Vasudev 2012)
Urinary Cast Formation
Urine Microscopy can be helpful in work up of chronic kidney disease
In GNrsquos the red blood cells leak from the glomerulus into the tubules As they traverse through the tubules they can form cylindrical casts calledRBC casts
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileRedbloodcellsjpgThis image is a work of the National Institutes of Health part of the United States Department of Health and Human Services As a work of the US federal government the image is in the public domain
(Vasudev amp Vasudev 2012)
IF YOU HAVE ALBUMINURIA OR HEMATURIA-ORDER THE FOLLOWING LABS
Tests of autoimmunity Hepatitis serologies gt40 years- paraproteinassessment
ANA Hepatitis B serology (HBsAG)
Serum protein electrophoresis (SPEP)
RFanti-ccp Hepatitis C serology(HCV antibody)
Urine protein electrophoresis (UPEP)
Complement C3 C4
ANCANational Kidney Disease Education Program 2014 NIH
UPTODATE LAB RECOMENDATIONS
bull Lab to order cbc cmp urine albumincr ratio urine microscopy
bull Nephrotic pattern (protein gt35gday) ANA anti DS DNA C3 and C4 antibodies HIV HBV HCV serumurine immunofixation (amyloidosis) free light chain analysis (light chain deposition disease)
bull Nephritic pattern (red cells white cells casts variable protein) C3 C4 ANA dsDNA antineutrophil cytoplasmic antibody (ANCA) titers a streptozyme test HBV and HCV serologies HIV and in some cases blood cultures anti-glomerular basement membrane (GBM) antibodies and cryoglobulins
bull Renal biopsy(Hebert amp Parikh 2014)
EVALUATION OF NEW CKDNO OBSTRUCTION
NO EVIDENCE OF GLOMERULAR BLEEDING
High risk for multmyeloma (gt40
no nsaids no contrast
SPEP UPEP with immunofixation serum free light
chains
Evaluation depends on UA
Sterile pyuria
Eval for interstitial nephritis
Normal urinalysis
High risk for renovascular
disease
Eval for renovascular
disease
Follow serum creatinine-does it
remain stable(Fatehi amp Chi-yuan 2016)
POSSIBLE INVESTIGATIONShellip
Acute interstitial nephritisbull Drugs are the most common cause of AIN
DIABETIC NEPHROPATHY 1 CAUSE OF CKDbull Clinical syndromebull Albuminuria gt30 mg 24 hrsbull Proteinuria gt500 mg24 hrsbull Hypertension developsbull Progressive increase in proteinuriabull Progressive decline in glomerular filtration rate
bull Chronic kidney disease should be attributed to diabetic nephropathies in most patients with diabetes if albuminuria and diabetic retinopathy are both present other causes of CKD should be entertained if diabetic retinopathy is absent (KDIGO 2007)
DIABETIC NEPHROPATHY MORTALITY
bull After 40 yrs of DM
bull 10 alive if proteinuria is present
bull 70 alive if proteinuria is absent
bull Heart Disease is 15 times higher risk in those with proteinuria
bull Proteinuria = death in this population
Dunkler et al 2015
GOALS OF CARE IN CKD GLUCOSE CONTROL
bull Target HbA1c ~70 (lt695 greatest chance of reducing albuminuria)bull Can be extended above 70 with comorbidities or limited life expectancy and
risk of hypoglycemiabull Risk of hypoglycemia increases as kidney function becomes impairedbull Declining kidney function may necessitate changes to diabetes medications and
bull Just having HTN can cause proteinuriabull Usually 1-2 gms of protein a daybull Treat them like a diabetic with ACEI or ARBS and tight blood
pressure controlbull JNC-8 goal lt14090 for ptrsquos with CKDbull National kidney foundation lt14090 if ckd and no proteinuria
lt13080 if proteinuria present
(James Ortiz amp Et Al 2014)
TREATING HYPERTENSIONPROTEINURIA ACEI ORARBbull Riskbenefit should be carefully assessed in the elderly and medically fragilebull Check labs after initiation
bull If less than 30 SCr increase continue and monitorbull If more than 30 SCr increase stop ACEi and evaluate for renal artery stenosis
bull Continue until contraindication arises no absolute eGFR cutoffbull Better proteinuria suppression with low Na diet and diureticsbull Avoid volume depletionbull Avoid ACEi and ARB in combination12
bull Risk of adverse events (impaired kidney function hyperkalemia)
(Kunz Friedrich Wolbers amp Mann 2008)(Mann Schmieder amp McQueen 2008)
bull In adults gt50 yrs statin when eGFR ge 60 mlmin173m2 statin or statinezetimibe combination when eGFR lt 60 mlmin173m2
bull In adults lt 50 yrs statin if history of known CAD MI DM strokebull Aspirin is indicated for secondary but not primary prevention
Kidney Disease Improving Global Outcomes (KDIGO) CKD Work Group Kidney Int Suppls 201331-150
STATINS-RENOPROTECTIVECONTROVERSY
bull HMG-CoA reductase inhibitors (statins) in high doses can cause proteinuria
bull Possibly associated with less inflammation endothelial dysfunction and scarring in the kidney because they also block inflammatory cytokines
bull Use statins for CV disease not to treat proteinuria
(Afzali and Goldsmith 2016)
MEDICINE CAUTION
bull Hold metformin when gfr lt35 mlmin
bull GFR lt50 mlmin should alert to check all doses of meds
bull No bisphosphanates lt35 mlmin
bull No NSAIDScox 2 inhibitors lt60 mlmin
bull Atenolol ndashrenal excretion
bull BACTRIM A lot of AKI
MEDICINE CAUTION
bull Lovenox-use subcut heparinbull Apixibanbull Dabigatranbull Rivaroxibanbull Lithiumbull GABAPENTIN (ckd 4 max 300mg qd ckd 5 max 300mg qod)
STEPS TO CKD PATIENT CARE
1 CKD definition and risks2 Assess GFR albuminuria3 Determine etiology4 Assess for evidence of progression5 Assess for associated complications6 Discuss dialysistransplantation
CKD-CVD-DIABETES LINK CKD IS A DISEASE MULTIPLIER
National kidney foundation 2014
KDIGO 2017
CKD-MINERAL BONE DISORDERS
bull As kidneys fail they
bull Stop activating calcitriol (the active form of Vit D)mdashcausing calcium imbalance
bull Do not remove phosphorus from bloodmdashleading to phosphorus retention
bull The extra phosphorus pulls calcium out of bones causing them to weaken
bull High phosphorus stimulates PTH release
bull These changes (plus others) cause the start of secondary hyperparathyroidism
bull Labs
bull eGFR
bull Calcium
bull Phos
bull Vit D
bull iPTH
(Qunibi amp Henrich 2017)
PREVALENCE OF ABNORMALITIES OF MINERAL METABOLISM PTH IN CKD
bull Progression of disease ndash declining eGFR increasing proteinuria
bull Degree of proteinuria nephrotic syndrome gt 05-10 gd on ACEi or ARB therapy
bull Etiology of CKD not certain
bull Need help with disease management
bull Indications for kidney biopsy
Rosenberg 2016
WHEN TO REFER
STEPS TO CKD PATIENT CARE
1 CKD definition and risks2 Assess GFR albuminuria3 Determine etiology4 Assess for evidence of progression5 Assess for associated complications6 Discuss dialysistransplantation
KIDNEY TRANSPLANTATION
bull Treatment of choice for ESRDbull Improves quality of lifebull Waiting list time varies-3-5 yearsbull 3 year survival rate after transplantation is 83-94bull Increased risk of cancer
STARTING DIALYSIS IN THE ELDERLYhellipOR NOT
bull Among patients gt 75 yrs with stage 5 CKD who chose to NOT start dialysisbull Overall more likely to die over next 1-2 years bull But if they had ischemic heart disease or other significant comorbidity NO
DIFFERENCE in survival
bull Active disease management and supportive care may be appropriate without starting dialysis in the ill elderly
bull Palliative care does not mean ldquono carerdquo
bull Must have end-of-life discussions
(Murtagh et al 2007)
CKD MANAGEMENTbull Diagnose cause and treat underlying conditionbull Stage per guidelinesbull Slow progression of kidney disease (ACE inhibitors)bull Monitor for complicationsmdashvolume overload hyperkalemia metabolic acidosis
hyperphosphatemia anorexia fatigue htn bone diseasebull Labs cmp cbc phos Vit D 25OH iPTH urine microscopy uric acid urine
proteincr ratio-frequency based off heat map Get sono at least oncebull Vaccinate influenza hep B pneumococcalbull Eval ASCVD risk-likely needs statinbull Possible dexa (donrsquot give bisphosphonates if GFRlt35 let specialist manage)bull Refer to nephrology when eGFR is lt30 (sometimes if higher risk-refer earlier)
CASE 1
bull 55 year old man with past medical history of headaches presents to your office for his first time visit to a PCP in over 30 years
bull He has no past history of being admitted to the hospital and he does not take any OTC medsNSAIDsherbal meds He has no history of ETOH abuse smoking or drug use
bull Vitals BP 180100 mmHg pulse 80 R 18
bull Exam No JVD S1S2 regular PMI shifted to the left no gallop no abdominal bruit pulses bilaterally equal and regular no leg edema
bull What would you order
bull EKG cbc cmp ua urine proteincr ratio lipid
LAB RESULTS
bull Labs reveal a creatinine of 22 mgdL eGFR 33 Urine shows no blood or casts Urineprotein ratio shows 1 gm protein24 hrs EKG shows LVH
bull Next step in workupbull Renal ultrasound 1st then SPEP UPEP with immunofixation serum free light chains
bull Additional labs neg Renal ultrasound shows that both kidneys are slightly reduced in size and are mildly echogenic with no mass or hydronephrosis
bull What is your diagnosis
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileMain_complications_of_persistent_high_blood_pressurepngCreative Commons License associated httpcreativecommonsorglicensesby-sa30
bull 3 months Howevermdashwe have evidence of structural abnormalities Could potentially stage at G3b A3 (red on the heat map)
bull Goal blood pressure
bull JNC 8 14090 NKF 13080
bull Additional lab needed for progression monitoring
bull Cbc renal panel phos Vit D iPTH uric acid urine micro (we already have the renal sono and urine proteincr ratio and lipid)
Selective renal angiography (left lower renal artery) after successful percutaneous balloon dilatation of the stenotic lesionFibromuscular dysplasia in an accessory renal artery causing renovascular hypertension
Secondary Hypertension
Images retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileRenal_FMD2jpg and httpcommonswikimediaorgwikiFileRenal_FMDjpgCreative Commons License associated httpcreativecommonsorglicensesby20deeden (both images)
CASE 2bull OS is a 64year old Hispanic female in for DM check She has had DM for 15+ years and is currently
taking metformin 1000mg bid Lisinopril 10mg a day atorvastatin 40mg a day Labs today showed the following
bull Hgba1c 86 cmp eGFR 50 lipid WNL proteincr ratio 650mg These results are similar to her last visit
bull Upon further hx-you find that she had a recent eye exam and has mild nonproliferaive retinopathy She does not have neuropathy or other ss
bull What further workup do you need
bull Renal sonogram urine micro iPTH vit D (25 OH) phos uric acid
bull Dx stage
bull G3a A3
bull What further treatment do you need
bull Improve glycemic control Increase Lisinopril to 20mg with a goal of 40mg Avoid NSAIDs or other nephrotoxic agents make sure meds are renally dosed monitor 3xyear nephro referral
MANAGEMENT OF CKD IN DIABETESeGFR Recommended
All patients
Yearly measurement of creatinine urinary albumin excretion potassium
45-60 Referral to a nephrologist if possibility for nondiabetickidney disease existsConsider dose adjustment of medicationsMonitor eGFR every 6 monthsMonitor electrolytes bicarbonate hemoglobin calcium phosphorus parathyroid hormone at least yearly
Assure vitamin D sufficiencyConsider bone density testingReferral for dietary counselling
American Diabetes Association Standards of Medical Care in Diabetes Microvascular complications and foot care Diabetes Care 2017 40 (Suppl 1) S88-S98
CASE 3
bull 19 year old African American woman presents to your clinic with complaints of fatigue joint pains a new rash on her face oral ulcer
bull On exam BP 15080 P 88 Afebrile 96 O2 sats on RAbull GEN No respiratory distress at restbull HEENT painless oral ulcer flat rash over malar eminences sparing the nasolabial fold pallor +bull Lungs CTAbull CVS S1S2 regularbull Abdomen soft NTbull Ext left elbow joint and bilateral wrist joints are swollen and tender
bull What would you orderbull CBC CMP ua urine microscopy (microalbumin or urine proteincr ratio) ANA esr RF anti-ccp uric acid TSH
CASE 3
bull Working dx fatigue oral ulcer joint pain
bull Basic Labs Na 135 K 55 Bicarb 18 BUN 50 Cr 35 eGFR 22 Ca 90 ANA + titer 1640
bull UA 3+ blood 3+ protein RBC casts +
bull Given these results what is the most likely diagnosis
bull What would you do
SYSTEMIC LUPUS ERYTHEMATOSUS (SLE)
bull SLE multisystemic disease Etiology unknown
bull Production of autoantibodies and immune complexes formation
bull There is renal involvement in the great majority of patients with SLE at some time of the evolution 66-90
SLE ndash LUPUS NEPHRITIS
bull Race SLE is more commonsevere in African americans than Caucasiansbull
bull Gender female-to-male ratio of 91
bull Age Most patients develop lupus nephritis early in their disease course SLE is more common among women in the third decade of life and lupus nephritis occurs in patients aged 20-40 years
bull Kidney Biopsy For staging lupus nephritis (Class 1-5)
CASE 5bull A 80 year old man who has not seen a PCP in many years
presents to your clinic for weakness for the past few months On further questioning he tells you that his bones also have been hurting lately and he has developed leg swelling in the past month or so
bull On exam bull BP 16090 P 88 Afebrilebull GEN Thin built manbull HEENT pallor presentbull Lungs clearbull CVS S1S2 regular no rub or gallopbull Abdomen soft NTbull Ext 2 + edema
CASE 5
bull Differentials
bull CHF MI Cancer arthritis
bull Labs
bull CBC CMP urine microscopy urine proteincr ratio ESR TSH EKG BNP pa and lat CXR
bull LABS Urine dipstick negative for protein or blood
bull Basic chem bull Na 136 (135-145) K 51 (35-55) Chloride 108 (96-106) Bicarb 25
Given this presentation and the labs (low anion gap and elevated calcium anemia kidney failure) what will you think of What will you order next
Serum and urine protein electrophoresis
Intratubular refractile casts with surrounding syncytial giant cell reaction with chronic tubulointerstitial nephritis and fibrosis characteristic of myeloma cast nephropathy
Kidney Biopsy
CASE STUDYbull A 35 year old African American woman was seen in the clinic for
chronic cough and dyspnea on exertion She gave history of vague symptoms of fatigue and weight loss of 20 Ibs over the last six months
bull List some differentialsbull TB sarcoid lupus thyroid problems PEbull What would you orderbull PPD cbc cmp UA TSH ANA pa and lat cxr
bull Her labs were significant for mildly elevated calcium level and a creatinine of 20 mgdL eGFR 37
bull She had 750 mg of proteinuriaday
bull PPD neg ANA neg TSH and other labs WNL
bull Assuming this is present more than 3 monthshelliphellipwhat is her ckd stage
bull G3b A3
bull What do we still need
CT scan of chest
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileAnterior_mediastinal_mass_thymomajpgCreative Commons License associated httpcreativecommonsorglicensesby20deeden
CXR ndash HILAR LYMPHADENOPATHY
WHATS NEEDED NEXT
bull Biopsy of hilar lymphadenopathy or renal biopsy
bull DX sarcoidosis
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileSarcoidosis_signs_and_symptomsjpgThis work is in the public domain in the United States because it is a work of the United States Federal Government under the terms of Title 17 Chapter 1 Section 105 of the US Code
NEWLY DX CKD
bull 1) urinalysis microscopy ultrasound proteincr ratio
bull If obstruction-treat
bull No obstruction
bull Hx critical (consider myeloma if high risk)
bull glomerular bleeding or albumin in urine
bull Yes workup for glomerular causes (ANArf hep B C upep spep ANCA complement C3 C4)
bull No sterile pyruria-consider interstitial nephritis
bull High risk renovascular disease Evaluate renovascular disease
Additional Online Resources for CKD LearningbullNational Kidney Foundation wwwkidneyorgbullUnited States Renal Data Service wwwusrdsorgbullCDCrsquos CKD Surveillance Project
httpnccdcdcgovckdbullNational Kidney Disease Education Program
(NKDEP) httpnkdepnihgov
BIBLIOGRAPHY
bull Afzali B amp Goldsmith D J (2016 June 29) Statins and chronic kidney disease (G C Curhan amp A M Sheridan Eds) Retrieved 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsstatins-and-chronic-kidney-disease
bull American Diabetes Association Standards of Medical Care in Diabetes (2017) Microvascular complications and foot care Diabetes Care 2017 (40) S88-S98
bull American Diabetes Association Standards of Medical Care in Diabetes (2017) Microvascular complications and foot care Diabetes Care 40 (suppl 1) S88-S98
bull Berns J S (2017 Mar 22) Treatment of anemia in nondialysis chronic kidney disease (T A Golper amp A M Sheridan Eds) Retrieved from UpToDate httpswww-uptodate-comproxywichitaeducontentstreatment-of-anemia-in-nondialysis-chronic-kidney-disease
bull Chan M Dall A T Fletcher K E Lu N amp Trivedi H (2007) Outcomes in patients with chronic kidney disease referred late to nephrologists a meta-analysis American Journal of Medicine 120(12) 1063-1070
bull Coresh J Selvin E amp Stevens L A (2007) Prevalence of chronic kidny disease in the United States JAMA 298(17) doi101001jama298172038
bull de Brito-Ashurst I Varagunam M Raftery M amp Yagoob M (2009) Bicarbonate supplementation slows progression of CKD and improves nutritional status Journal of American Society of Nephrology (20) 2075-2084
BIBLIOGRAPHY
bull Duncan L Heathcoat J Djurdjev O amp Levin A (2001) Screening for renal disease using serum creatinine who are we missing Nephrology Dialysis and Transplant 16(5) 1042-1046
bull Dunkler D Gao P Lee S F Heinz G Clase C M Tobe S Oberbauer R (2015 August 7) Risk prediction for early CKD in type 2 diabetes Retrieved from Clinical Journal of the American Society of Nephrology httpcjasnasnjournalsorgcontent1081371fullsid=61422554-a5f1-41ac-b696-dcd3b12bd268
bull Fatehi P amp Chi-yuan H (September 15 2016) Diagnostic approach to the patient with newly identified chronic kidney disease (G C Curhan amp A M Sheridan Eds) Retrieved May 7 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsdiagnostic-approach-to-the-patient-with-newly-identified-chronic-kidney-disease
bull Fink J e (2009) Chronic Kidney Disease as an Under-Recognized Threat to Patient Safety American journal of kidney diseases the official journal of the National Kidney Foundation 53(4) 681-688
bull Gaffo A L amp Saag K G (2008 Nov) Management of hyperuricemia and gout in CKD doihttpdxdoiorg101053jajkd200807035
bull Hebert L A amp Parikh S V (2014 June 18) Differential diagnosis and evaluation of glomerular disease (R J Glassock amp A Q Lam Eds) Retrieved May 7 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsdifferential-diagnosis-and-evaluation-of-glomerular-disease
bull Inker L Perrone R D Sterns R H amp Forman J P (2017 March 7) Assessment of kidney function Retrieved from UpToDate httpswww-uptodate-comproxywichitaeducontentsassessment-of-kidney-functionsource=search_resultampsearch=creatinineampselectedTitle=1~150
BIBLIOGRAPHY
bull James P A Ortiz E amp Et Al (2014) Evidence based guideline for the management of high blood pressure in adults (JNC) JAMA 311(5) 507-520
bull Kidney Disease Improving Global Outcomes (KDIGO) CKD Work Group (2013 January) KDIGO 2012 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease Retrieved from Kidney International Supplement httpwwwkidney-internationalorg
bull Kunz R Friedrich C Wolbers M amp Mann J F (2008) Meta-analysis effect of monotherapy and combination therapy with inhibitors of the renin angiotensin system on proteinuria in renal disease Annals of Internal Medicine 148(1) 30-48
bull Levey A Stevens L A Schmid C H Castro A F Feldman H I Kusek J W Coresh J (2009) A new equation to estimate glomerular filtration rate Annals of Internal Medicine 150(9) 604-612
bull Levin A Bakris G L Molitch M Smulders M M Williams L A amp Andress D L (2007 Jan) Prevalence of abnormal serum vitamin D PTH calcium and phosphorus in patients with chronic kidney disease results of the study to evaluate early kidney disease Kidney International 71(1) 31-38 Retrieved from PubMED
bull Mahajan A Simoni J Sheather S Broglio K Rajab M amp Wesson D (2010) Daily oral sodium bicarbonate preserves glomerular filtration rate by slowing its decline in early hypertensive nephropathy Kidney International (78_ 303-309
bull Mann J Schmieder R E amp McQueen M (2008) Renal outcomes with telmisartan ramipril or both in people at high vascular risk (the ONTARGET study) a multicentre randomised doubleblind ocntrolled trial Lancet 372(9638) 547-533
BIBLIOGRAPHY
bull Matovinović M S (2009) Pathophysiology and classification of kidney disease Retrieved from The Journal of the International Federation of Clinical Chemistry and Laboratory Medicine httpwwwifccorgifccfilesdocs20010902pdf
bull Moe S Drueke T Lameire N amp Eknoyan G (2007 Jan) Chronic kidney disease-mineral-bone disorder a new paradigmdoi101053jackd200610005
bull Murtagh F E Marsh J E Donohoe P Ekbal N J Sheerin N S amp Harris F E (2007 July) Dialysis or not A comparative survival study of patients over 75 years with chronic kidney disease stage 5 Retrieved from Nephrology Dialysis and Transplant 22(7) httpswwwncbinlmnihgovpubmed17412702
bull National Kidney Foundation (2002) KDOQI clinical practice guidelines for chronic kidney disease evaluation classification andstratification American Journal of Kidney Disease S1-S266
bull National Kidney Foundation (2014 November 5) Fact Sheets Retrieved from httpwwwkidneyorgnewsnewsroomfactsheetsFastFacts
bull Pal S (2012 June 2) Trends in chronic kidney disease Retrieved from US Pharmacist (37)6 httpswwwuspharmacistcomarticletrends-in-chronic-kidney-disease
bull Qunibi W amp Henrich W L (2017 Jan 19) Overview of chronic kidney disease-mineral and bone disorder (J Berns amp A M Sheridan Eds) Retrieved from UpToDate httpswww-uptodate-comoverview-of-chronic-kidney-disease-mineral-and-bone-disorder-ckd-mbd
bull Rosenberg M (2016 Feb 24) Overview of the management of chronic kidney disease in adults (G C Curhan amp A M Sheridan Eds) Retrieved from UpToDate UpToDate httpswww-uptodate-comproxywichitaeducontentsoverview-of-the-management-of-chronic-kidney-disease-in-adults
BIBLIOGRAPHY
bull Szczech L Stewart R C Hsu-Lin S DeLosky R J Astor B C Fox C H Vassalotti J A (2014) Primary care detection of chronic kidney disease in adults with type 2 diabetes The ADD-CKD Study (Awareness Detection and Drug Therapy in type 2 diabetes and chronic kidney disease PLOS doihttpsdoiorg101371journalpone0110535
bull USRDS (2016) Annual data report 2016 Epidemiology of kidney disease in the United States Retrieved from United States Renal Data System httpswwwusrdsorgadraspx
bull Vasudev B amp Vasudev M (2012) A model curriculum for residents rotating in nephrology MedEDPORTAL doihttpdoiorg1015766mep_2374-82658288
bull Wei L MacDonald T M Jennings C Sheng X amp Flynn R W (2013) Estimated GFR reporting is associated with decreased nonsteroidal anti-inflammatory drug prescribing and increased renal function Kidney International (84)1 174-178
chronic kidney disease in primary care
CKD as a Public Health Issue
Slide Number 3
Costs of CKD in 2013 dollarsUSRDS report
Steps to CKD Patient Care
Renal anatomy and physiology
Definition of Chronic Kidney Disease
CKD Risk Factors
Gaps in CKD Diagnosis
Slide Number 10
Steps to CKD Patient Care
creatinine
Glomerular filtration rate
Slide Number 14
Slide Number 15
Use These Equations Cautiously if at all in hellip
lab albumin creatinine ratio
The New CKD Categories
Steps to CKD Patient Care
Slide Number 20
Kidney Involvement in Systemic Diseases
Slide Number 22
Slide Number 23
DysmorphicRenal Hematuria
Slide Number 25
If you have albuminuria or hematuria-order the following labs
bull Structural or functional abnormalities of the kidneys with our without decreased GFR manifest by either
bull Pathological abnormalities
bull Markers of kidney damage including abnormalities in the composition of the blood or urine or in imaging tests
bull GFR lt 60 mlmin173 m2 for gt 3 months with or without kidney damage as defined above
(Kidney Disease Improving Global Outcomes (KDIGO) CKD Work Group 2013)
CKD RISK FACTORS
Modifiablebull Diabetesbull Hypertensionbull History of AKIbull Frequent NSAID use
bull Obesity
bull Hyperuricemia
bull Smoking
bull Sedentary lifestyle
bull Dietary Protein Intake
Non-modifiablebull Family history of kidney disease diabetes or
hypertension
bull Age 60 or older (GFR declines normally with age)
bull RaceUS ethnic minority status
Partial listAKI acute kidney injury (Kidney Disease Improving Global Outcomes (KDIGO) CKD Work Group 2013)
GAPS IN CKD DIAGNOSIS
Szczech Lynda A et al Primary Care Detection of Chronic Kidney Disease in Adults with Type-2 Diabetes The ADD-CKD Study (Awareness Detection and Drug Therapy in Type-2 Diabetes and Chronic Kidney Disease) PLOS One - In press (2014)
0
10
20
30
40
50
60
Not Appropriately Tested Appropriately tested - no diagnosis Appropriately tested - accurate diagnosis
CKD Screening in Primary Care( of patients)
of Patients
Improved Diagnosishellip
Studies demonstrate that clinician behavior changes when CKD diagnosis improves Significant improvements realized in1-3
bull Increased urinary albumin testingbull Increased appropriate use of ACEi or ARBbull Avoidance of NSAIDs prescribing among patients
with low eGFRbull Appropriate nephrology consultation
1 Wei L et al Kidney Int 201384174-1782 Chan M et al Am J Med 20071201063-10703 Fink J et al Am J Kidney Dis 200953681-668
STEPS TO CKD PATIENT CARE
1 CKD definition and risks2 Assess GFR albuminuria (knowing the labs)3 Determine etiology4 Slow progression5 Assess for associated complications6 Discuss dialysistransplantation
CREATININEbull Creatinine is derived from the metabolism of creatine in skeletal
muscle and from dietary meat intake
creatinine secretion by the renal tubules + creatine intake (ie diet)+ creatinine pool size (ie muscle mass) all remain constant
bull GFR is equal to the sum of the filtration rates in all of the functioning nephrons
bull Glomeruli filter 180Lday (125mLmin) of plasma
bull Normal GFR depends on age sex body size and is approximately 130mLmin for men and 120mLmin for womenmdashwith considerable variation
bull CKD-EPI equation (estimated GFR in mLmin173m2) is most accurate
Age Gender RaceSCr
(mgdL) eGFR (mLmin173 m2)
20 M B 13 91
20 M W 13 75
55 M W 13 61
20 F W 13 56
55 F B 13 55
50 F W 13 46
B = black W = all ethnic groups other than blackWith evidence of kidney damage
(Duncan Heathcoat Djurdjev amp Levin 2001)(National Kidney Foundation 2002)
or lt 15 mLmin173m2
(Levey et al 2009)
True GFR could be gt 70 mLmin173m2
The ldquoerdquo in eGFR Stands for ldquoEstimatedrdquohellip
USE THESE EQUATIONS CAUTIOUSLY IF AT ALL IN hellip
bull Patients who haveare
bull Poor nutritionloss of muscle mass
bull Amputation
bull Chronic illness
bull Not African American or Caucasian
bull Changing serum creatinine
bull Obese
bull Very elderly young
(National Kidney Foundation 2014)
LAB ALBUMIN CREATININE RATIO
bull Urinary albumin-to-creatinine ratio (ACR) is calculated by dividing albumin concentration in milligrams by creatinine concentration in grams
bull Creatinine assists in adjusting albumin levels for varying urine concentrations which allows for more accurate results versus albumin alone
bull Spot urine albumin-to-creatinine ratio for quantification of proteinuria
bull New guidelines classify albuminuria as mild moderately or severely increased
bull First morning void preferable
bull 24hr urine test rarely necessary
THE NEW CKD CATEGORIES
STEPS TO CKD PATIENT CARE
1 CKD definition and risks2 Assess GFR albuminuria3 Determine etiology- what is going on here4 Slow progression5 Assess for associated complications6 Discuss dialysistransplantation
(Pal 2012)
KIDNEY INVOLVEMENT IN SYSTEMIC DISEASES
Hypertension
DiabetesAmyloidosis
Sickle cell diseases
Immune complex GN
Illicit drugs ndash cocaine heroin
Cholesterol emboli
HIV
Allergic reactions- drugsinterstitial nephritis
Hemolytic Uremic syndrome
Lupus
Systemic vasculitis
Liver FailureCongestive heart Failure
Image retrieved on 05 October 2010 from httpenwikipediaorgwikiFileGray1129pngThis image is under the public domain and not copyrightable in the US as per Bridgeman Art Library v Corel Corp
(Vasudev amp Vasudev 2012)
New CKD
Obtain ultrasound UA
microscopy albumincr ratio
Ultrasound shows
obstruction
bull Yes Relieve obstruction
bull No Is there albuminuria or glomerular bleeding (eval for glomerulo-nephritis
Fatehi amp Chi-yuan 2016
If red cells have their typical shape and color this indicates extra glomerular hematuria
Examples kidney stone disease UTI cystitis bleeding from collecting duct ureters bladder or urethra
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileReactive_lymphJPGCreative Commons License associated httpcreativecommonsorglicensesby-sa30deeden
(Vasudev amp Vasudev 2012)
DYSMORPHICRENAL HEMATURIA
bull This hematuria is characterized by bull a great variation in the size of the cells and by a high
percentage of dysmorphocytosiscasts (gt20)
bull Hematuria is usually related to glomerular bleeding bull It is typically accompanied by variable levels of albumuniuria
(Vasudev amp Vasudev 2012)
Urinary Cast Formation
Urine Microscopy can be helpful in work up of chronic kidney disease
In GNrsquos the red blood cells leak from the glomerulus into the tubules As they traverse through the tubules they can form cylindrical casts calledRBC casts
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileRedbloodcellsjpgThis image is a work of the National Institutes of Health part of the United States Department of Health and Human Services As a work of the US federal government the image is in the public domain
(Vasudev amp Vasudev 2012)
IF YOU HAVE ALBUMINURIA OR HEMATURIA-ORDER THE FOLLOWING LABS
Tests of autoimmunity Hepatitis serologies gt40 years- paraproteinassessment
ANA Hepatitis B serology (HBsAG)
Serum protein electrophoresis (SPEP)
RFanti-ccp Hepatitis C serology(HCV antibody)
Urine protein electrophoresis (UPEP)
Complement C3 C4
ANCANational Kidney Disease Education Program 2014 NIH
UPTODATE LAB RECOMENDATIONS
bull Lab to order cbc cmp urine albumincr ratio urine microscopy
bull Nephrotic pattern (protein gt35gday) ANA anti DS DNA C3 and C4 antibodies HIV HBV HCV serumurine immunofixation (amyloidosis) free light chain analysis (light chain deposition disease)
bull Nephritic pattern (red cells white cells casts variable protein) C3 C4 ANA dsDNA antineutrophil cytoplasmic antibody (ANCA) titers a streptozyme test HBV and HCV serologies HIV and in some cases blood cultures anti-glomerular basement membrane (GBM) antibodies and cryoglobulins
bull Renal biopsy(Hebert amp Parikh 2014)
EVALUATION OF NEW CKDNO OBSTRUCTION
NO EVIDENCE OF GLOMERULAR BLEEDING
High risk for multmyeloma (gt40
no nsaids no contrast
SPEP UPEP with immunofixation serum free light
chains
Evaluation depends on UA
Sterile pyuria
Eval for interstitial nephritis
Normal urinalysis
High risk for renovascular
disease
Eval for renovascular
disease
Follow serum creatinine-does it
remain stable(Fatehi amp Chi-yuan 2016)
POSSIBLE INVESTIGATIONShellip
Acute interstitial nephritisbull Drugs are the most common cause of AIN
DIABETIC NEPHROPATHY 1 CAUSE OF CKDbull Clinical syndromebull Albuminuria gt30 mg 24 hrsbull Proteinuria gt500 mg24 hrsbull Hypertension developsbull Progressive increase in proteinuriabull Progressive decline in glomerular filtration rate
bull Chronic kidney disease should be attributed to diabetic nephropathies in most patients with diabetes if albuminuria and diabetic retinopathy are both present other causes of CKD should be entertained if diabetic retinopathy is absent (KDIGO 2007)
DIABETIC NEPHROPATHY MORTALITY
bull After 40 yrs of DM
bull 10 alive if proteinuria is present
bull 70 alive if proteinuria is absent
bull Heart Disease is 15 times higher risk in those with proteinuria
bull Proteinuria = death in this population
Dunkler et al 2015
GOALS OF CARE IN CKD GLUCOSE CONTROL
bull Target HbA1c ~70 (lt695 greatest chance of reducing albuminuria)bull Can be extended above 70 with comorbidities or limited life expectancy and
risk of hypoglycemiabull Risk of hypoglycemia increases as kidney function becomes impairedbull Declining kidney function may necessitate changes to diabetes medications and
bull Just having HTN can cause proteinuriabull Usually 1-2 gms of protein a daybull Treat them like a diabetic with ACEI or ARBS and tight blood
pressure controlbull JNC-8 goal lt14090 for ptrsquos with CKDbull National kidney foundation lt14090 if ckd and no proteinuria
lt13080 if proteinuria present
(James Ortiz amp Et Al 2014)
TREATING HYPERTENSIONPROTEINURIA ACEI ORARBbull Riskbenefit should be carefully assessed in the elderly and medically fragilebull Check labs after initiation
bull If less than 30 SCr increase continue and monitorbull If more than 30 SCr increase stop ACEi and evaluate for renal artery stenosis
bull Continue until contraindication arises no absolute eGFR cutoffbull Better proteinuria suppression with low Na diet and diureticsbull Avoid volume depletionbull Avoid ACEi and ARB in combination12
bull Risk of adverse events (impaired kidney function hyperkalemia)
(Kunz Friedrich Wolbers amp Mann 2008)(Mann Schmieder amp McQueen 2008)
bull In adults gt50 yrs statin when eGFR ge 60 mlmin173m2 statin or statinezetimibe combination when eGFR lt 60 mlmin173m2
bull In adults lt 50 yrs statin if history of known CAD MI DM strokebull Aspirin is indicated for secondary but not primary prevention
Kidney Disease Improving Global Outcomes (KDIGO) CKD Work Group Kidney Int Suppls 201331-150
STATINS-RENOPROTECTIVECONTROVERSY
bull HMG-CoA reductase inhibitors (statins) in high doses can cause proteinuria
bull Possibly associated with less inflammation endothelial dysfunction and scarring in the kidney because they also block inflammatory cytokines
bull Use statins for CV disease not to treat proteinuria
(Afzali and Goldsmith 2016)
MEDICINE CAUTION
bull Hold metformin when gfr lt35 mlmin
bull GFR lt50 mlmin should alert to check all doses of meds
bull No bisphosphanates lt35 mlmin
bull No NSAIDScox 2 inhibitors lt60 mlmin
bull Atenolol ndashrenal excretion
bull BACTRIM A lot of AKI
MEDICINE CAUTION
bull Lovenox-use subcut heparinbull Apixibanbull Dabigatranbull Rivaroxibanbull Lithiumbull GABAPENTIN (ckd 4 max 300mg qd ckd 5 max 300mg qod)
STEPS TO CKD PATIENT CARE
1 CKD definition and risks2 Assess GFR albuminuria3 Determine etiology4 Assess for evidence of progression5 Assess for associated complications6 Discuss dialysistransplantation
CKD-CVD-DIABETES LINK CKD IS A DISEASE MULTIPLIER
National kidney foundation 2014
KDIGO 2017
CKD-MINERAL BONE DISORDERS
bull As kidneys fail they
bull Stop activating calcitriol (the active form of Vit D)mdashcausing calcium imbalance
bull Do not remove phosphorus from bloodmdashleading to phosphorus retention
bull The extra phosphorus pulls calcium out of bones causing them to weaken
bull High phosphorus stimulates PTH release
bull These changes (plus others) cause the start of secondary hyperparathyroidism
bull Labs
bull eGFR
bull Calcium
bull Phos
bull Vit D
bull iPTH
(Qunibi amp Henrich 2017)
PREVALENCE OF ABNORMALITIES OF MINERAL METABOLISM PTH IN CKD
bull Progression of disease ndash declining eGFR increasing proteinuria
bull Degree of proteinuria nephrotic syndrome gt 05-10 gd on ACEi or ARB therapy
bull Etiology of CKD not certain
bull Need help with disease management
bull Indications for kidney biopsy
Rosenberg 2016
WHEN TO REFER
STEPS TO CKD PATIENT CARE
1 CKD definition and risks2 Assess GFR albuminuria3 Determine etiology4 Assess for evidence of progression5 Assess for associated complications6 Discuss dialysistransplantation
KIDNEY TRANSPLANTATION
bull Treatment of choice for ESRDbull Improves quality of lifebull Waiting list time varies-3-5 yearsbull 3 year survival rate after transplantation is 83-94bull Increased risk of cancer
STARTING DIALYSIS IN THE ELDERLYhellipOR NOT
bull Among patients gt 75 yrs with stage 5 CKD who chose to NOT start dialysisbull Overall more likely to die over next 1-2 years bull But if they had ischemic heart disease or other significant comorbidity NO
DIFFERENCE in survival
bull Active disease management and supportive care may be appropriate without starting dialysis in the ill elderly
bull Palliative care does not mean ldquono carerdquo
bull Must have end-of-life discussions
(Murtagh et al 2007)
CKD MANAGEMENTbull Diagnose cause and treat underlying conditionbull Stage per guidelinesbull Slow progression of kidney disease (ACE inhibitors)bull Monitor for complicationsmdashvolume overload hyperkalemia metabolic acidosis
hyperphosphatemia anorexia fatigue htn bone diseasebull Labs cmp cbc phos Vit D 25OH iPTH urine microscopy uric acid urine
proteincr ratio-frequency based off heat map Get sono at least oncebull Vaccinate influenza hep B pneumococcalbull Eval ASCVD risk-likely needs statinbull Possible dexa (donrsquot give bisphosphonates if GFRlt35 let specialist manage)bull Refer to nephrology when eGFR is lt30 (sometimes if higher risk-refer earlier)
CASE 1
bull 55 year old man with past medical history of headaches presents to your office for his first time visit to a PCP in over 30 years
bull He has no past history of being admitted to the hospital and he does not take any OTC medsNSAIDsherbal meds He has no history of ETOH abuse smoking or drug use
bull Vitals BP 180100 mmHg pulse 80 R 18
bull Exam No JVD S1S2 regular PMI shifted to the left no gallop no abdominal bruit pulses bilaterally equal and regular no leg edema
bull What would you order
bull EKG cbc cmp ua urine proteincr ratio lipid
LAB RESULTS
bull Labs reveal a creatinine of 22 mgdL eGFR 33 Urine shows no blood or casts Urineprotein ratio shows 1 gm protein24 hrs EKG shows LVH
bull Next step in workupbull Renal ultrasound 1st then SPEP UPEP with immunofixation serum free light chains
bull Additional labs neg Renal ultrasound shows that both kidneys are slightly reduced in size and are mildly echogenic with no mass or hydronephrosis
bull What is your diagnosis
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileMain_complications_of_persistent_high_blood_pressurepngCreative Commons License associated httpcreativecommonsorglicensesby-sa30
bull 3 months Howevermdashwe have evidence of structural abnormalities Could potentially stage at G3b A3 (red on the heat map)
bull Goal blood pressure
bull JNC 8 14090 NKF 13080
bull Additional lab needed for progression monitoring
bull Cbc renal panel phos Vit D iPTH uric acid urine micro (we already have the renal sono and urine proteincr ratio and lipid)
Selective renal angiography (left lower renal artery) after successful percutaneous balloon dilatation of the stenotic lesionFibromuscular dysplasia in an accessory renal artery causing renovascular hypertension
Secondary Hypertension
Images retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileRenal_FMD2jpg and httpcommonswikimediaorgwikiFileRenal_FMDjpgCreative Commons License associated httpcreativecommonsorglicensesby20deeden (both images)
CASE 2bull OS is a 64year old Hispanic female in for DM check She has had DM for 15+ years and is currently
taking metformin 1000mg bid Lisinopril 10mg a day atorvastatin 40mg a day Labs today showed the following
bull Hgba1c 86 cmp eGFR 50 lipid WNL proteincr ratio 650mg These results are similar to her last visit
bull Upon further hx-you find that she had a recent eye exam and has mild nonproliferaive retinopathy She does not have neuropathy or other ss
bull What further workup do you need
bull Renal sonogram urine micro iPTH vit D (25 OH) phos uric acid
bull Dx stage
bull G3a A3
bull What further treatment do you need
bull Improve glycemic control Increase Lisinopril to 20mg with a goal of 40mg Avoid NSAIDs or other nephrotoxic agents make sure meds are renally dosed monitor 3xyear nephro referral
MANAGEMENT OF CKD IN DIABETESeGFR Recommended
All patients
Yearly measurement of creatinine urinary albumin excretion potassium
45-60 Referral to a nephrologist if possibility for nondiabetickidney disease existsConsider dose adjustment of medicationsMonitor eGFR every 6 monthsMonitor electrolytes bicarbonate hemoglobin calcium phosphorus parathyroid hormone at least yearly
Assure vitamin D sufficiencyConsider bone density testingReferral for dietary counselling
American Diabetes Association Standards of Medical Care in Diabetes Microvascular complications and foot care Diabetes Care 2017 40 (Suppl 1) S88-S98
CASE 3
bull 19 year old African American woman presents to your clinic with complaints of fatigue joint pains a new rash on her face oral ulcer
bull On exam BP 15080 P 88 Afebrile 96 O2 sats on RAbull GEN No respiratory distress at restbull HEENT painless oral ulcer flat rash over malar eminences sparing the nasolabial fold pallor +bull Lungs CTAbull CVS S1S2 regularbull Abdomen soft NTbull Ext left elbow joint and bilateral wrist joints are swollen and tender
bull What would you orderbull CBC CMP ua urine microscopy (microalbumin or urine proteincr ratio) ANA esr RF anti-ccp uric acid TSH
CASE 3
bull Working dx fatigue oral ulcer joint pain
bull Basic Labs Na 135 K 55 Bicarb 18 BUN 50 Cr 35 eGFR 22 Ca 90 ANA + titer 1640
bull UA 3+ blood 3+ protein RBC casts +
bull Given these results what is the most likely diagnosis
bull What would you do
SYSTEMIC LUPUS ERYTHEMATOSUS (SLE)
bull SLE multisystemic disease Etiology unknown
bull Production of autoantibodies and immune complexes formation
bull There is renal involvement in the great majority of patients with SLE at some time of the evolution 66-90
SLE ndash LUPUS NEPHRITIS
bull Race SLE is more commonsevere in African americans than Caucasiansbull
bull Gender female-to-male ratio of 91
bull Age Most patients develop lupus nephritis early in their disease course SLE is more common among women in the third decade of life and lupus nephritis occurs in patients aged 20-40 years
bull Kidney Biopsy For staging lupus nephritis (Class 1-5)
CASE 5bull A 80 year old man who has not seen a PCP in many years
presents to your clinic for weakness for the past few months On further questioning he tells you that his bones also have been hurting lately and he has developed leg swelling in the past month or so
bull On exam bull BP 16090 P 88 Afebrilebull GEN Thin built manbull HEENT pallor presentbull Lungs clearbull CVS S1S2 regular no rub or gallopbull Abdomen soft NTbull Ext 2 + edema
CASE 5
bull Differentials
bull CHF MI Cancer arthritis
bull Labs
bull CBC CMP urine microscopy urine proteincr ratio ESR TSH EKG BNP pa and lat CXR
bull LABS Urine dipstick negative for protein or blood
bull Basic chem bull Na 136 (135-145) K 51 (35-55) Chloride 108 (96-106) Bicarb 25
Given this presentation and the labs (low anion gap and elevated calcium anemia kidney failure) what will you think of What will you order next
Serum and urine protein electrophoresis
Intratubular refractile casts with surrounding syncytial giant cell reaction with chronic tubulointerstitial nephritis and fibrosis characteristic of myeloma cast nephropathy
Kidney Biopsy
CASE STUDYbull A 35 year old African American woman was seen in the clinic for
chronic cough and dyspnea on exertion She gave history of vague symptoms of fatigue and weight loss of 20 Ibs over the last six months
bull List some differentialsbull TB sarcoid lupus thyroid problems PEbull What would you orderbull PPD cbc cmp UA TSH ANA pa and lat cxr
bull Her labs were significant for mildly elevated calcium level and a creatinine of 20 mgdL eGFR 37
bull She had 750 mg of proteinuriaday
bull PPD neg ANA neg TSH and other labs WNL
bull Assuming this is present more than 3 monthshelliphellipwhat is her ckd stage
bull G3b A3
bull What do we still need
CT scan of chest
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileAnterior_mediastinal_mass_thymomajpgCreative Commons License associated httpcreativecommonsorglicensesby20deeden
CXR ndash HILAR LYMPHADENOPATHY
WHATS NEEDED NEXT
bull Biopsy of hilar lymphadenopathy or renal biopsy
bull DX sarcoidosis
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileSarcoidosis_signs_and_symptomsjpgThis work is in the public domain in the United States because it is a work of the United States Federal Government under the terms of Title 17 Chapter 1 Section 105 of the US Code
NEWLY DX CKD
bull 1) urinalysis microscopy ultrasound proteincr ratio
bull If obstruction-treat
bull No obstruction
bull Hx critical (consider myeloma if high risk)
bull glomerular bleeding or albumin in urine
bull Yes workup for glomerular causes (ANArf hep B C upep spep ANCA complement C3 C4)
bull No sterile pyruria-consider interstitial nephritis
bull High risk renovascular disease Evaluate renovascular disease
Additional Online Resources for CKD LearningbullNational Kidney Foundation wwwkidneyorgbullUnited States Renal Data Service wwwusrdsorgbullCDCrsquos CKD Surveillance Project
httpnccdcdcgovckdbullNational Kidney Disease Education Program
(NKDEP) httpnkdepnihgov
BIBLIOGRAPHY
bull Afzali B amp Goldsmith D J (2016 June 29) Statins and chronic kidney disease (G C Curhan amp A M Sheridan Eds) Retrieved 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsstatins-and-chronic-kidney-disease
bull American Diabetes Association Standards of Medical Care in Diabetes (2017) Microvascular complications and foot care Diabetes Care 2017 (40) S88-S98
bull American Diabetes Association Standards of Medical Care in Diabetes (2017) Microvascular complications and foot care Diabetes Care 40 (suppl 1) S88-S98
bull Berns J S (2017 Mar 22) Treatment of anemia in nondialysis chronic kidney disease (T A Golper amp A M Sheridan Eds) Retrieved from UpToDate httpswww-uptodate-comproxywichitaeducontentstreatment-of-anemia-in-nondialysis-chronic-kidney-disease
bull Chan M Dall A T Fletcher K E Lu N amp Trivedi H (2007) Outcomes in patients with chronic kidney disease referred late to nephrologists a meta-analysis American Journal of Medicine 120(12) 1063-1070
bull Coresh J Selvin E amp Stevens L A (2007) Prevalence of chronic kidny disease in the United States JAMA 298(17) doi101001jama298172038
bull de Brito-Ashurst I Varagunam M Raftery M amp Yagoob M (2009) Bicarbonate supplementation slows progression of CKD and improves nutritional status Journal of American Society of Nephrology (20) 2075-2084
BIBLIOGRAPHY
bull Duncan L Heathcoat J Djurdjev O amp Levin A (2001) Screening for renal disease using serum creatinine who are we missing Nephrology Dialysis and Transplant 16(5) 1042-1046
bull Dunkler D Gao P Lee S F Heinz G Clase C M Tobe S Oberbauer R (2015 August 7) Risk prediction for early CKD in type 2 diabetes Retrieved from Clinical Journal of the American Society of Nephrology httpcjasnasnjournalsorgcontent1081371fullsid=61422554-a5f1-41ac-b696-dcd3b12bd268
bull Fatehi P amp Chi-yuan H (September 15 2016) Diagnostic approach to the patient with newly identified chronic kidney disease (G C Curhan amp A M Sheridan Eds) Retrieved May 7 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsdiagnostic-approach-to-the-patient-with-newly-identified-chronic-kidney-disease
bull Fink J e (2009) Chronic Kidney Disease as an Under-Recognized Threat to Patient Safety American journal of kidney diseases the official journal of the National Kidney Foundation 53(4) 681-688
bull Gaffo A L amp Saag K G (2008 Nov) Management of hyperuricemia and gout in CKD doihttpdxdoiorg101053jajkd200807035
bull Hebert L A amp Parikh S V (2014 June 18) Differential diagnosis and evaluation of glomerular disease (R J Glassock amp A Q Lam Eds) Retrieved May 7 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsdifferential-diagnosis-and-evaluation-of-glomerular-disease
bull Inker L Perrone R D Sterns R H amp Forman J P (2017 March 7) Assessment of kidney function Retrieved from UpToDate httpswww-uptodate-comproxywichitaeducontentsassessment-of-kidney-functionsource=search_resultampsearch=creatinineampselectedTitle=1~150
BIBLIOGRAPHY
bull James P A Ortiz E amp Et Al (2014) Evidence based guideline for the management of high blood pressure in adults (JNC) JAMA 311(5) 507-520
bull Kidney Disease Improving Global Outcomes (KDIGO) CKD Work Group (2013 January) KDIGO 2012 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease Retrieved from Kidney International Supplement httpwwwkidney-internationalorg
bull Kunz R Friedrich C Wolbers M amp Mann J F (2008) Meta-analysis effect of monotherapy and combination therapy with inhibitors of the renin angiotensin system on proteinuria in renal disease Annals of Internal Medicine 148(1) 30-48
bull Levey A Stevens L A Schmid C H Castro A F Feldman H I Kusek J W Coresh J (2009) A new equation to estimate glomerular filtration rate Annals of Internal Medicine 150(9) 604-612
bull Levin A Bakris G L Molitch M Smulders M M Williams L A amp Andress D L (2007 Jan) Prevalence of abnormal serum vitamin D PTH calcium and phosphorus in patients with chronic kidney disease results of the study to evaluate early kidney disease Kidney International 71(1) 31-38 Retrieved from PubMED
bull Mahajan A Simoni J Sheather S Broglio K Rajab M amp Wesson D (2010) Daily oral sodium bicarbonate preserves glomerular filtration rate by slowing its decline in early hypertensive nephropathy Kidney International (78_ 303-309
bull Mann J Schmieder R E amp McQueen M (2008) Renal outcomes with telmisartan ramipril or both in people at high vascular risk (the ONTARGET study) a multicentre randomised doubleblind ocntrolled trial Lancet 372(9638) 547-533
BIBLIOGRAPHY
bull Matovinović M S (2009) Pathophysiology and classification of kidney disease Retrieved from The Journal of the International Federation of Clinical Chemistry and Laboratory Medicine httpwwwifccorgifccfilesdocs20010902pdf
bull Moe S Drueke T Lameire N amp Eknoyan G (2007 Jan) Chronic kidney disease-mineral-bone disorder a new paradigmdoi101053jackd200610005
bull Murtagh F E Marsh J E Donohoe P Ekbal N J Sheerin N S amp Harris F E (2007 July) Dialysis or not A comparative survival study of patients over 75 years with chronic kidney disease stage 5 Retrieved from Nephrology Dialysis and Transplant 22(7) httpswwwncbinlmnihgovpubmed17412702
bull National Kidney Foundation (2002) KDOQI clinical practice guidelines for chronic kidney disease evaluation classification andstratification American Journal of Kidney Disease S1-S266
bull National Kidney Foundation (2014 November 5) Fact Sheets Retrieved from httpwwwkidneyorgnewsnewsroomfactsheetsFastFacts
bull Pal S (2012 June 2) Trends in chronic kidney disease Retrieved from US Pharmacist (37)6 httpswwwuspharmacistcomarticletrends-in-chronic-kidney-disease
bull Qunibi W amp Henrich W L (2017 Jan 19) Overview of chronic kidney disease-mineral and bone disorder (J Berns amp A M Sheridan Eds) Retrieved from UpToDate httpswww-uptodate-comoverview-of-chronic-kidney-disease-mineral-and-bone-disorder-ckd-mbd
bull Rosenberg M (2016 Feb 24) Overview of the management of chronic kidney disease in adults (G C Curhan amp A M Sheridan Eds) Retrieved from UpToDate UpToDate httpswww-uptodate-comproxywichitaeducontentsoverview-of-the-management-of-chronic-kidney-disease-in-adults
BIBLIOGRAPHY
bull Szczech L Stewart R C Hsu-Lin S DeLosky R J Astor B C Fox C H Vassalotti J A (2014) Primary care detection of chronic kidney disease in adults with type 2 diabetes The ADD-CKD Study (Awareness Detection and Drug Therapy in type 2 diabetes and chronic kidney disease PLOS doihttpsdoiorg101371journalpone0110535
bull USRDS (2016) Annual data report 2016 Epidemiology of kidney disease in the United States Retrieved from United States Renal Data System httpswwwusrdsorgadraspx
bull Vasudev B amp Vasudev M (2012) A model curriculum for residents rotating in nephrology MedEDPORTAL doihttpdoiorg1015766mep_2374-82658288
bull Wei L MacDonald T M Jennings C Sheng X amp Flynn R W (2013) Estimated GFR reporting is associated with decreased nonsteroidal anti-inflammatory drug prescribing and increased renal function Kidney International (84)1 174-178
chronic kidney disease in primary care
CKD as a Public Health Issue
Slide Number 3
Costs of CKD in 2013 dollarsUSRDS report
Steps to CKD Patient Care
Renal anatomy and physiology
Definition of Chronic Kidney Disease
CKD Risk Factors
Gaps in CKD Diagnosis
Slide Number 10
Steps to CKD Patient Care
creatinine
Glomerular filtration rate
Slide Number 14
Slide Number 15
Use These Equations Cautiously if at all in hellip
lab albumin creatinine ratio
The New CKD Categories
Steps to CKD Patient Care
Slide Number 20
Kidney Involvement in Systemic Diseases
Slide Number 22
Slide Number 23
DysmorphicRenal Hematuria
Slide Number 25
If you have albuminuria or hematuria-order the following labs
bull Structural or functional abnormalities of the kidneys with our without decreased GFR manifest by either
bull Pathological abnormalities
bull Markers of kidney damage including abnormalities in the composition of the blood or urine or in imaging tests
bull GFR lt 60 mlmin173 m2 for gt 3 months with or without kidney damage as defined above
(Kidney Disease Improving Global Outcomes (KDIGO) CKD Work Group 2013)
CKD RISK FACTORS
Modifiablebull Diabetesbull Hypertensionbull History of AKIbull Frequent NSAID use
bull Obesity
bull Hyperuricemia
bull Smoking
bull Sedentary lifestyle
bull Dietary Protein Intake
Non-modifiablebull Family history of kidney disease diabetes or
hypertension
bull Age 60 or older (GFR declines normally with age)
bull RaceUS ethnic minority status
Partial listAKI acute kidney injury (Kidney Disease Improving Global Outcomes (KDIGO) CKD Work Group 2013)
GAPS IN CKD DIAGNOSIS
Szczech Lynda A et al Primary Care Detection of Chronic Kidney Disease in Adults with Type-2 Diabetes The ADD-CKD Study (Awareness Detection and Drug Therapy in Type-2 Diabetes and Chronic Kidney Disease) PLOS One - In press (2014)
0
10
20
30
40
50
60
Not Appropriately Tested Appropriately tested - no diagnosis Appropriately tested - accurate diagnosis
CKD Screening in Primary Care( of patients)
of Patients
Improved Diagnosishellip
Studies demonstrate that clinician behavior changes when CKD diagnosis improves Significant improvements realized in1-3
bull Increased urinary albumin testingbull Increased appropriate use of ACEi or ARBbull Avoidance of NSAIDs prescribing among patients
with low eGFRbull Appropriate nephrology consultation
1 Wei L et al Kidney Int 201384174-1782 Chan M et al Am J Med 20071201063-10703 Fink J et al Am J Kidney Dis 200953681-668
STEPS TO CKD PATIENT CARE
1 CKD definition and risks2 Assess GFR albuminuria (knowing the labs)3 Determine etiology4 Slow progression5 Assess for associated complications6 Discuss dialysistransplantation
CREATININEbull Creatinine is derived from the metabolism of creatine in skeletal
muscle and from dietary meat intake
creatinine secretion by the renal tubules + creatine intake (ie diet)+ creatinine pool size (ie muscle mass) all remain constant
bull GFR is equal to the sum of the filtration rates in all of the functioning nephrons
bull Glomeruli filter 180Lday (125mLmin) of plasma
bull Normal GFR depends on age sex body size and is approximately 130mLmin for men and 120mLmin for womenmdashwith considerable variation
bull CKD-EPI equation (estimated GFR in mLmin173m2) is most accurate
Age Gender RaceSCr
(mgdL) eGFR (mLmin173 m2)
20 M B 13 91
20 M W 13 75
55 M W 13 61
20 F W 13 56
55 F B 13 55
50 F W 13 46
B = black W = all ethnic groups other than blackWith evidence of kidney damage
(Duncan Heathcoat Djurdjev amp Levin 2001)(National Kidney Foundation 2002)
or lt 15 mLmin173m2
(Levey et al 2009)
True GFR could be gt 70 mLmin173m2
The ldquoerdquo in eGFR Stands for ldquoEstimatedrdquohellip
USE THESE EQUATIONS CAUTIOUSLY IF AT ALL IN hellip
bull Patients who haveare
bull Poor nutritionloss of muscle mass
bull Amputation
bull Chronic illness
bull Not African American or Caucasian
bull Changing serum creatinine
bull Obese
bull Very elderly young
(National Kidney Foundation 2014)
LAB ALBUMIN CREATININE RATIO
bull Urinary albumin-to-creatinine ratio (ACR) is calculated by dividing albumin concentration in milligrams by creatinine concentration in grams
bull Creatinine assists in adjusting albumin levels for varying urine concentrations which allows for more accurate results versus albumin alone
bull Spot urine albumin-to-creatinine ratio for quantification of proteinuria
bull New guidelines classify albuminuria as mild moderately or severely increased
bull First morning void preferable
bull 24hr urine test rarely necessary
THE NEW CKD CATEGORIES
STEPS TO CKD PATIENT CARE
1 CKD definition and risks2 Assess GFR albuminuria3 Determine etiology- what is going on here4 Slow progression5 Assess for associated complications6 Discuss dialysistransplantation
(Pal 2012)
KIDNEY INVOLVEMENT IN SYSTEMIC DISEASES
Hypertension
DiabetesAmyloidosis
Sickle cell diseases
Immune complex GN
Illicit drugs ndash cocaine heroin
Cholesterol emboli
HIV
Allergic reactions- drugsinterstitial nephritis
Hemolytic Uremic syndrome
Lupus
Systemic vasculitis
Liver FailureCongestive heart Failure
Image retrieved on 05 October 2010 from httpenwikipediaorgwikiFileGray1129pngThis image is under the public domain and not copyrightable in the US as per Bridgeman Art Library v Corel Corp
(Vasudev amp Vasudev 2012)
New CKD
Obtain ultrasound UA
microscopy albumincr ratio
Ultrasound shows
obstruction
bull Yes Relieve obstruction
bull No Is there albuminuria or glomerular bleeding (eval for glomerulo-nephritis
Fatehi amp Chi-yuan 2016
If red cells have their typical shape and color this indicates extra glomerular hematuria
Examples kidney stone disease UTI cystitis bleeding from collecting duct ureters bladder or urethra
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileReactive_lymphJPGCreative Commons License associated httpcreativecommonsorglicensesby-sa30deeden
(Vasudev amp Vasudev 2012)
DYSMORPHICRENAL HEMATURIA
bull This hematuria is characterized by bull a great variation in the size of the cells and by a high
percentage of dysmorphocytosiscasts (gt20)
bull Hematuria is usually related to glomerular bleeding bull It is typically accompanied by variable levels of albumuniuria
(Vasudev amp Vasudev 2012)
Urinary Cast Formation
Urine Microscopy can be helpful in work up of chronic kidney disease
In GNrsquos the red blood cells leak from the glomerulus into the tubules As they traverse through the tubules they can form cylindrical casts calledRBC casts
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileRedbloodcellsjpgThis image is a work of the National Institutes of Health part of the United States Department of Health and Human Services As a work of the US federal government the image is in the public domain
(Vasudev amp Vasudev 2012)
IF YOU HAVE ALBUMINURIA OR HEMATURIA-ORDER THE FOLLOWING LABS
Tests of autoimmunity Hepatitis serologies gt40 years- paraproteinassessment
ANA Hepatitis B serology (HBsAG)
Serum protein electrophoresis (SPEP)
RFanti-ccp Hepatitis C serology(HCV antibody)
Urine protein electrophoresis (UPEP)
Complement C3 C4
ANCANational Kidney Disease Education Program 2014 NIH
UPTODATE LAB RECOMENDATIONS
bull Lab to order cbc cmp urine albumincr ratio urine microscopy
bull Nephrotic pattern (protein gt35gday) ANA anti DS DNA C3 and C4 antibodies HIV HBV HCV serumurine immunofixation (amyloidosis) free light chain analysis (light chain deposition disease)
bull Nephritic pattern (red cells white cells casts variable protein) C3 C4 ANA dsDNA antineutrophil cytoplasmic antibody (ANCA) titers a streptozyme test HBV and HCV serologies HIV and in some cases blood cultures anti-glomerular basement membrane (GBM) antibodies and cryoglobulins
bull Renal biopsy(Hebert amp Parikh 2014)
EVALUATION OF NEW CKDNO OBSTRUCTION
NO EVIDENCE OF GLOMERULAR BLEEDING
High risk for multmyeloma (gt40
no nsaids no contrast
SPEP UPEP with immunofixation serum free light
chains
Evaluation depends on UA
Sterile pyuria
Eval for interstitial nephritis
Normal urinalysis
High risk for renovascular
disease
Eval for renovascular
disease
Follow serum creatinine-does it
remain stable(Fatehi amp Chi-yuan 2016)
POSSIBLE INVESTIGATIONShellip
Acute interstitial nephritisbull Drugs are the most common cause of AIN
DIABETIC NEPHROPATHY 1 CAUSE OF CKDbull Clinical syndromebull Albuminuria gt30 mg 24 hrsbull Proteinuria gt500 mg24 hrsbull Hypertension developsbull Progressive increase in proteinuriabull Progressive decline in glomerular filtration rate
bull Chronic kidney disease should be attributed to diabetic nephropathies in most patients with diabetes if albuminuria and diabetic retinopathy are both present other causes of CKD should be entertained if diabetic retinopathy is absent (KDIGO 2007)
DIABETIC NEPHROPATHY MORTALITY
bull After 40 yrs of DM
bull 10 alive if proteinuria is present
bull 70 alive if proteinuria is absent
bull Heart Disease is 15 times higher risk in those with proteinuria
bull Proteinuria = death in this population
Dunkler et al 2015
GOALS OF CARE IN CKD GLUCOSE CONTROL
bull Target HbA1c ~70 (lt695 greatest chance of reducing albuminuria)bull Can be extended above 70 with comorbidities or limited life expectancy and
risk of hypoglycemiabull Risk of hypoglycemia increases as kidney function becomes impairedbull Declining kidney function may necessitate changes to diabetes medications and
bull Just having HTN can cause proteinuriabull Usually 1-2 gms of protein a daybull Treat them like a diabetic with ACEI or ARBS and tight blood
pressure controlbull JNC-8 goal lt14090 for ptrsquos with CKDbull National kidney foundation lt14090 if ckd and no proteinuria
lt13080 if proteinuria present
(James Ortiz amp Et Al 2014)
TREATING HYPERTENSIONPROTEINURIA ACEI ORARBbull Riskbenefit should be carefully assessed in the elderly and medically fragilebull Check labs after initiation
bull If less than 30 SCr increase continue and monitorbull If more than 30 SCr increase stop ACEi and evaluate for renal artery stenosis
bull Continue until contraindication arises no absolute eGFR cutoffbull Better proteinuria suppression with low Na diet and diureticsbull Avoid volume depletionbull Avoid ACEi and ARB in combination12
bull Risk of adverse events (impaired kidney function hyperkalemia)
(Kunz Friedrich Wolbers amp Mann 2008)(Mann Schmieder amp McQueen 2008)
bull In adults gt50 yrs statin when eGFR ge 60 mlmin173m2 statin or statinezetimibe combination when eGFR lt 60 mlmin173m2
bull In adults lt 50 yrs statin if history of known CAD MI DM strokebull Aspirin is indicated for secondary but not primary prevention
Kidney Disease Improving Global Outcomes (KDIGO) CKD Work Group Kidney Int Suppls 201331-150
STATINS-RENOPROTECTIVECONTROVERSY
bull HMG-CoA reductase inhibitors (statins) in high doses can cause proteinuria
bull Possibly associated with less inflammation endothelial dysfunction and scarring in the kidney because they also block inflammatory cytokines
bull Use statins for CV disease not to treat proteinuria
(Afzali and Goldsmith 2016)
MEDICINE CAUTION
bull Hold metformin when gfr lt35 mlmin
bull GFR lt50 mlmin should alert to check all doses of meds
bull No bisphosphanates lt35 mlmin
bull No NSAIDScox 2 inhibitors lt60 mlmin
bull Atenolol ndashrenal excretion
bull BACTRIM A lot of AKI
MEDICINE CAUTION
bull Lovenox-use subcut heparinbull Apixibanbull Dabigatranbull Rivaroxibanbull Lithiumbull GABAPENTIN (ckd 4 max 300mg qd ckd 5 max 300mg qod)
STEPS TO CKD PATIENT CARE
1 CKD definition and risks2 Assess GFR albuminuria3 Determine etiology4 Assess for evidence of progression5 Assess for associated complications6 Discuss dialysistransplantation
CKD-CVD-DIABETES LINK CKD IS A DISEASE MULTIPLIER
National kidney foundation 2014
KDIGO 2017
CKD-MINERAL BONE DISORDERS
bull As kidneys fail they
bull Stop activating calcitriol (the active form of Vit D)mdashcausing calcium imbalance
bull Do not remove phosphorus from bloodmdashleading to phosphorus retention
bull The extra phosphorus pulls calcium out of bones causing them to weaken
bull High phosphorus stimulates PTH release
bull These changes (plus others) cause the start of secondary hyperparathyroidism
bull Labs
bull eGFR
bull Calcium
bull Phos
bull Vit D
bull iPTH
(Qunibi amp Henrich 2017)
PREVALENCE OF ABNORMALITIES OF MINERAL METABOLISM PTH IN CKD
bull Progression of disease ndash declining eGFR increasing proteinuria
bull Degree of proteinuria nephrotic syndrome gt 05-10 gd on ACEi or ARB therapy
bull Etiology of CKD not certain
bull Need help with disease management
bull Indications for kidney biopsy
Rosenberg 2016
WHEN TO REFER
STEPS TO CKD PATIENT CARE
1 CKD definition and risks2 Assess GFR albuminuria3 Determine etiology4 Assess for evidence of progression5 Assess for associated complications6 Discuss dialysistransplantation
KIDNEY TRANSPLANTATION
bull Treatment of choice for ESRDbull Improves quality of lifebull Waiting list time varies-3-5 yearsbull 3 year survival rate after transplantation is 83-94bull Increased risk of cancer
STARTING DIALYSIS IN THE ELDERLYhellipOR NOT
bull Among patients gt 75 yrs with stage 5 CKD who chose to NOT start dialysisbull Overall more likely to die over next 1-2 years bull But if they had ischemic heart disease or other significant comorbidity NO
DIFFERENCE in survival
bull Active disease management and supportive care may be appropriate without starting dialysis in the ill elderly
bull Palliative care does not mean ldquono carerdquo
bull Must have end-of-life discussions
(Murtagh et al 2007)
CKD MANAGEMENTbull Diagnose cause and treat underlying conditionbull Stage per guidelinesbull Slow progression of kidney disease (ACE inhibitors)bull Monitor for complicationsmdashvolume overload hyperkalemia metabolic acidosis
hyperphosphatemia anorexia fatigue htn bone diseasebull Labs cmp cbc phos Vit D 25OH iPTH urine microscopy uric acid urine
proteincr ratio-frequency based off heat map Get sono at least oncebull Vaccinate influenza hep B pneumococcalbull Eval ASCVD risk-likely needs statinbull Possible dexa (donrsquot give bisphosphonates if GFRlt35 let specialist manage)bull Refer to nephrology when eGFR is lt30 (sometimes if higher risk-refer earlier)
CASE 1
bull 55 year old man with past medical history of headaches presents to your office for his first time visit to a PCP in over 30 years
bull He has no past history of being admitted to the hospital and he does not take any OTC medsNSAIDsherbal meds He has no history of ETOH abuse smoking or drug use
bull Vitals BP 180100 mmHg pulse 80 R 18
bull Exam No JVD S1S2 regular PMI shifted to the left no gallop no abdominal bruit pulses bilaterally equal and regular no leg edema
bull What would you order
bull EKG cbc cmp ua urine proteincr ratio lipid
LAB RESULTS
bull Labs reveal a creatinine of 22 mgdL eGFR 33 Urine shows no blood or casts Urineprotein ratio shows 1 gm protein24 hrs EKG shows LVH
bull Next step in workupbull Renal ultrasound 1st then SPEP UPEP with immunofixation serum free light chains
bull Additional labs neg Renal ultrasound shows that both kidneys are slightly reduced in size and are mildly echogenic with no mass or hydronephrosis
bull What is your diagnosis
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileMain_complications_of_persistent_high_blood_pressurepngCreative Commons License associated httpcreativecommonsorglicensesby-sa30
bull 3 months Howevermdashwe have evidence of structural abnormalities Could potentially stage at G3b A3 (red on the heat map)
bull Goal blood pressure
bull JNC 8 14090 NKF 13080
bull Additional lab needed for progression monitoring
bull Cbc renal panel phos Vit D iPTH uric acid urine micro (we already have the renal sono and urine proteincr ratio and lipid)
Selective renal angiography (left lower renal artery) after successful percutaneous balloon dilatation of the stenotic lesionFibromuscular dysplasia in an accessory renal artery causing renovascular hypertension
Secondary Hypertension
Images retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileRenal_FMD2jpg and httpcommonswikimediaorgwikiFileRenal_FMDjpgCreative Commons License associated httpcreativecommonsorglicensesby20deeden (both images)
CASE 2bull OS is a 64year old Hispanic female in for DM check She has had DM for 15+ years and is currently
taking metformin 1000mg bid Lisinopril 10mg a day atorvastatin 40mg a day Labs today showed the following
bull Hgba1c 86 cmp eGFR 50 lipid WNL proteincr ratio 650mg These results are similar to her last visit
bull Upon further hx-you find that she had a recent eye exam and has mild nonproliferaive retinopathy She does not have neuropathy or other ss
bull What further workup do you need
bull Renal sonogram urine micro iPTH vit D (25 OH) phos uric acid
bull Dx stage
bull G3a A3
bull What further treatment do you need
bull Improve glycemic control Increase Lisinopril to 20mg with a goal of 40mg Avoid NSAIDs or other nephrotoxic agents make sure meds are renally dosed monitor 3xyear nephro referral
MANAGEMENT OF CKD IN DIABETESeGFR Recommended
All patients
Yearly measurement of creatinine urinary albumin excretion potassium
45-60 Referral to a nephrologist if possibility for nondiabetickidney disease existsConsider dose adjustment of medicationsMonitor eGFR every 6 monthsMonitor electrolytes bicarbonate hemoglobin calcium phosphorus parathyroid hormone at least yearly
Assure vitamin D sufficiencyConsider bone density testingReferral for dietary counselling
American Diabetes Association Standards of Medical Care in Diabetes Microvascular complications and foot care Diabetes Care 2017 40 (Suppl 1) S88-S98
CASE 3
bull 19 year old African American woman presents to your clinic with complaints of fatigue joint pains a new rash on her face oral ulcer
bull On exam BP 15080 P 88 Afebrile 96 O2 sats on RAbull GEN No respiratory distress at restbull HEENT painless oral ulcer flat rash over malar eminences sparing the nasolabial fold pallor +bull Lungs CTAbull CVS S1S2 regularbull Abdomen soft NTbull Ext left elbow joint and bilateral wrist joints are swollen and tender
bull What would you orderbull CBC CMP ua urine microscopy (microalbumin or urine proteincr ratio) ANA esr RF anti-ccp uric acid TSH
CASE 3
bull Working dx fatigue oral ulcer joint pain
bull Basic Labs Na 135 K 55 Bicarb 18 BUN 50 Cr 35 eGFR 22 Ca 90 ANA + titer 1640
bull UA 3+ blood 3+ protein RBC casts +
bull Given these results what is the most likely diagnosis
bull What would you do
SYSTEMIC LUPUS ERYTHEMATOSUS (SLE)
bull SLE multisystemic disease Etiology unknown
bull Production of autoantibodies and immune complexes formation
bull There is renal involvement in the great majority of patients with SLE at some time of the evolution 66-90
SLE ndash LUPUS NEPHRITIS
bull Race SLE is more commonsevere in African americans than Caucasiansbull
bull Gender female-to-male ratio of 91
bull Age Most patients develop lupus nephritis early in their disease course SLE is more common among women in the third decade of life and lupus nephritis occurs in patients aged 20-40 years
bull Kidney Biopsy For staging lupus nephritis (Class 1-5)
CASE 5bull A 80 year old man who has not seen a PCP in many years
presents to your clinic for weakness for the past few months On further questioning he tells you that his bones also have been hurting lately and he has developed leg swelling in the past month or so
bull On exam bull BP 16090 P 88 Afebrilebull GEN Thin built manbull HEENT pallor presentbull Lungs clearbull CVS S1S2 regular no rub or gallopbull Abdomen soft NTbull Ext 2 + edema
CASE 5
bull Differentials
bull CHF MI Cancer arthritis
bull Labs
bull CBC CMP urine microscopy urine proteincr ratio ESR TSH EKG BNP pa and lat CXR
bull LABS Urine dipstick negative for protein or blood
bull Basic chem bull Na 136 (135-145) K 51 (35-55) Chloride 108 (96-106) Bicarb 25
Given this presentation and the labs (low anion gap and elevated calcium anemia kidney failure) what will you think of What will you order next
Serum and urine protein electrophoresis
Intratubular refractile casts with surrounding syncytial giant cell reaction with chronic tubulointerstitial nephritis and fibrosis characteristic of myeloma cast nephropathy
Kidney Biopsy
CASE STUDYbull A 35 year old African American woman was seen in the clinic for
chronic cough and dyspnea on exertion She gave history of vague symptoms of fatigue and weight loss of 20 Ibs over the last six months
bull List some differentialsbull TB sarcoid lupus thyroid problems PEbull What would you orderbull PPD cbc cmp UA TSH ANA pa and lat cxr
bull Her labs were significant for mildly elevated calcium level and a creatinine of 20 mgdL eGFR 37
bull She had 750 mg of proteinuriaday
bull PPD neg ANA neg TSH and other labs WNL
bull Assuming this is present more than 3 monthshelliphellipwhat is her ckd stage
bull G3b A3
bull What do we still need
CT scan of chest
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileAnterior_mediastinal_mass_thymomajpgCreative Commons License associated httpcreativecommonsorglicensesby20deeden
CXR ndash HILAR LYMPHADENOPATHY
WHATS NEEDED NEXT
bull Biopsy of hilar lymphadenopathy or renal biopsy
bull DX sarcoidosis
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileSarcoidosis_signs_and_symptomsjpgThis work is in the public domain in the United States because it is a work of the United States Federal Government under the terms of Title 17 Chapter 1 Section 105 of the US Code
NEWLY DX CKD
bull 1) urinalysis microscopy ultrasound proteincr ratio
bull If obstruction-treat
bull No obstruction
bull Hx critical (consider myeloma if high risk)
bull glomerular bleeding or albumin in urine
bull Yes workup for glomerular causes (ANArf hep B C upep spep ANCA complement C3 C4)
bull No sterile pyruria-consider interstitial nephritis
bull High risk renovascular disease Evaluate renovascular disease
Additional Online Resources for CKD LearningbullNational Kidney Foundation wwwkidneyorgbullUnited States Renal Data Service wwwusrdsorgbullCDCrsquos CKD Surveillance Project
httpnccdcdcgovckdbullNational Kidney Disease Education Program
(NKDEP) httpnkdepnihgov
BIBLIOGRAPHY
bull Afzali B amp Goldsmith D J (2016 June 29) Statins and chronic kidney disease (G C Curhan amp A M Sheridan Eds) Retrieved 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsstatins-and-chronic-kidney-disease
bull American Diabetes Association Standards of Medical Care in Diabetes (2017) Microvascular complications and foot care Diabetes Care 2017 (40) S88-S98
bull American Diabetes Association Standards of Medical Care in Diabetes (2017) Microvascular complications and foot care Diabetes Care 40 (suppl 1) S88-S98
bull Berns J S (2017 Mar 22) Treatment of anemia in nondialysis chronic kidney disease (T A Golper amp A M Sheridan Eds) Retrieved from UpToDate httpswww-uptodate-comproxywichitaeducontentstreatment-of-anemia-in-nondialysis-chronic-kidney-disease
bull Chan M Dall A T Fletcher K E Lu N amp Trivedi H (2007) Outcomes in patients with chronic kidney disease referred late to nephrologists a meta-analysis American Journal of Medicine 120(12) 1063-1070
bull Coresh J Selvin E amp Stevens L A (2007) Prevalence of chronic kidny disease in the United States JAMA 298(17) doi101001jama298172038
bull de Brito-Ashurst I Varagunam M Raftery M amp Yagoob M (2009) Bicarbonate supplementation slows progression of CKD and improves nutritional status Journal of American Society of Nephrology (20) 2075-2084
BIBLIOGRAPHY
bull Duncan L Heathcoat J Djurdjev O amp Levin A (2001) Screening for renal disease using serum creatinine who are we missing Nephrology Dialysis and Transplant 16(5) 1042-1046
bull Dunkler D Gao P Lee S F Heinz G Clase C M Tobe S Oberbauer R (2015 August 7) Risk prediction for early CKD in type 2 diabetes Retrieved from Clinical Journal of the American Society of Nephrology httpcjasnasnjournalsorgcontent1081371fullsid=61422554-a5f1-41ac-b696-dcd3b12bd268
bull Fatehi P amp Chi-yuan H (September 15 2016) Diagnostic approach to the patient with newly identified chronic kidney disease (G C Curhan amp A M Sheridan Eds) Retrieved May 7 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsdiagnostic-approach-to-the-patient-with-newly-identified-chronic-kidney-disease
bull Fink J e (2009) Chronic Kidney Disease as an Under-Recognized Threat to Patient Safety American journal of kidney diseases the official journal of the National Kidney Foundation 53(4) 681-688
bull Gaffo A L amp Saag K G (2008 Nov) Management of hyperuricemia and gout in CKD doihttpdxdoiorg101053jajkd200807035
bull Hebert L A amp Parikh S V (2014 June 18) Differential diagnosis and evaluation of glomerular disease (R J Glassock amp A Q Lam Eds) Retrieved May 7 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsdifferential-diagnosis-and-evaluation-of-glomerular-disease
bull Inker L Perrone R D Sterns R H amp Forman J P (2017 March 7) Assessment of kidney function Retrieved from UpToDate httpswww-uptodate-comproxywichitaeducontentsassessment-of-kidney-functionsource=search_resultampsearch=creatinineampselectedTitle=1~150
BIBLIOGRAPHY
bull James P A Ortiz E amp Et Al (2014) Evidence based guideline for the management of high blood pressure in adults (JNC) JAMA 311(5) 507-520
bull Kidney Disease Improving Global Outcomes (KDIGO) CKD Work Group (2013 January) KDIGO 2012 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease Retrieved from Kidney International Supplement httpwwwkidney-internationalorg
bull Kunz R Friedrich C Wolbers M amp Mann J F (2008) Meta-analysis effect of monotherapy and combination therapy with inhibitors of the renin angiotensin system on proteinuria in renal disease Annals of Internal Medicine 148(1) 30-48
bull Levey A Stevens L A Schmid C H Castro A F Feldman H I Kusek J W Coresh J (2009) A new equation to estimate glomerular filtration rate Annals of Internal Medicine 150(9) 604-612
bull Levin A Bakris G L Molitch M Smulders M M Williams L A amp Andress D L (2007 Jan) Prevalence of abnormal serum vitamin D PTH calcium and phosphorus in patients with chronic kidney disease results of the study to evaluate early kidney disease Kidney International 71(1) 31-38 Retrieved from PubMED
bull Mahajan A Simoni J Sheather S Broglio K Rajab M amp Wesson D (2010) Daily oral sodium bicarbonate preserves glomerular filtration rate by slowing its decline in early hypertensive nephropathy Kidney International (78_ 303-309
bull Mann J Schmieder R E amp McQueen M (2008) Renal outcomes with telmisartan ramipril or both in people at high vascular risk (the ONTARGET study) a multicentre randomised doubleblind ocntrolled trial Lancet 372(9638) 547-533
BIBLIOGRAPHY
bull Matovinović M S (2009) Pathophysiology and classification of kidney disease Retrieved from The Journal of the International Federation of Clinical Chemistry and Laboratory Medicine httpwwwifccorgifccfilesdocs20010902pdf
bull Moe S Drueke T Lameire N amp Eknoyan G (2007 Jan) Chronic kidney disease-mineral-bone disorder a new paradigmdoi101053jackd200610005
bull Murtagh F E Marsh J E Donohoe P Ekbal N J Sheerin N S amp Harris F E (2007 July) Dialysis or not A comparative survival study of patients over 75 years with chronic kidney disease stage 5 Retrieved from Nephrology Dialysis and Transplant 22(7) httpswwwncbinlmnihgovpubmed17412702
bull National Kidney Foundation (2002) KDOQI clinical practice guidelines for chronic kidney disease evaluation classification andstratification American Journal of Kidney Disease S1-S266
bull National Kidney Foundation (2014 November 5) Fact Sheets Retrieved from httpwwwkidneyorgnewsnewsroomfactsheetsFastFacts
bull Pal S (2012 June 2) Trends in chronic kidney disease Retrieved from US Pharmacist (37)6 httpswwwuspharmacistcomarticletrends-in-chronic-kidney-disease
bull Qunibi W amp Henrich W L (2017 Jan 19) Overview of chronic kidney disease-mineral and bone disorder (J Berns amp A M Sheridan Eds) Retrieved from UpToDate httpswww-uptodate-comoverview-of-chronic-kidney-disease-mineral-and-bone-disorder-ckd-mbd
bull Rosenberg M (2016 Feb 24) Overview of the management of chronic kidney disease in adults (G C Curhan amp A M Sheridan Eds) Retrieved from UpToDate UpToDate httpswww-uptodate-comproxywichitaeducontentsoverview-of-the-management-of-chronic-kidney-disease-in-adults
BIBLIOGRAPHY
bull Szczech L Stewart R C Hsu-Lin S DeLosky R J Astor B C Fox C H Vassalotti J A (2014) Primary care detection of chronic kidney disease in adults with type 2 diabetes The ADD-CKD Study (Awareness Detection and Drug Therapy in type 2 diabetes and chronic kidney disease PLOS doihttpsdoiorg101371journalpone0110535
bull USRDS (2016) Annual data report 2016 Epidemiology of kidney disease in the United States Retrieved from United States Renal Data System httpswwwusrdsorgadraspx
bull Vasudev B amp Vasudev M (2012) A model curriculum for residents rotating in nephrology MedEDPORTAL doihttpdoiorg1015766mep_2374-82658288
bull Wei L MacDonald T M Jennings C Sheng X amp Flynn R W (2013) Estimated GFR reporting is associated with decreased nonsteroidal anti-inflammatory drug prescribing and increased renal function Kidney International (84)1 174-178
chronic kidney disease in primary care
CKD as a Public Health Issue
Slide Number 3
Costs of CKD in 2013 dollarsUSRDS report
Steps to CKD Patient Care
Renal anatomy and physiology
Definition of Chronic Kidney Disease
CKD Risk Factors
Gaps in CKD Diagnosis
Slide Number 10
Steps to CKD Patient Care
creatinine
Glomerular filtration rate
Slide Number 14
Slide Number 15
Use These Equations Cautiously if at all in hellip
lab albumin creatinine ratio
The New CKD Categories
Steps to CKD Patient Care
Slide Number 20
Kidney Involvement in Systemic Diseases
Slide Number 22
Slide Number 23
DysmorphicRenal Hematuria
Slide Number 25
If you have albuminuria or hematuria-order the following labs
bull Structural or functional abnormalities of the kidneys with our without decreased GFR manifest by either
bull Pathological abnormalities
bull Markers of kidney damage including abnormalities in the composition of the blood or urine or in imaging tests
bull GFR lt 60 mlmin173 m2 for gt 3 months with or without kidney damage as defined above
(Kidney Disease Improving Global Outcomes (KDIGO) CKD Work Group 2013)
CKD RISK FACTORS
Modifiablebull Diabetesbull Hypertensionbull History of AKIbull Frequent NSAID use
bull Obesity
bull Hyperuricemia
bull Smoking
bull Sedentary lifestyle
bull Dietary Protein Intake
Non-modifiablebull Family history of kidney disease diabetes or
hypertension
bull Age 60 or older (GFR declines normally with age)
bull RaceUS ethnic minority status
Partial listAKI acute kidney injury (Kidney Disease Improving Global Outcomes (KDIGO) CKD Work Group 2013)
GAPS IN CKD DIAGNOSIS
Szczech Lynda A et al Primary Care Detection of Chronic Kidney Disease in Adults with Type-2 Diabetes The ADD-CKD Study (Awareness Detection and Drug Therapy in Type-2 Diabetes and Chronic Kidney Disease) PLOS One - In press (2014)
0
10
20
30
40
50
60
Not Appropriately Tested Appropriately tested - no diagnosis Appropriately tested - accurate diagnosis
CKD Screening in Primary Care( of patients)
of Patients
Improved Diagnosishellip
Studies demonstrate that clinician behavior changes when CKD diagnosis improves Significant improvements realized in1-3
bull Increased urinary albumin testingbull Increased appropriate use of ACEi or ARBbull Avoidance of NSAIDs prescribing among patients
with low eGFRbull Appropriate nephrology consultation
1 Wei L et al Kidney Int 201384174-1782 Chan M et al Am J Med 20071201063-10703 Fink J et al Am J Kidney Dis 200953681-668
STEPS TO CKD PATIENT CARE
1 CKD definition and risks2 Assess GFR albuminuria (knowing the labs)3 Determine etiology4 Slow progression5 Assess for associated complications6 Discuss dialysistransplantation
CREATININEbull Creatinine is derived from the metabolism of creatine in skeletal
muscle and from dietary meat intake
creatinine secretion by the renal tubules + creatine intake (ie diet)+ creatinine pool size (ie muscle mass) all remain constant
bull GFR is equal to the sum of the filtration rates in all of the functioning nephrons
bull Glomeruli filter 180Lday (125mLmin) of plasma
bull Normal GFR depends on age sex body size and is approximately 130mLmin for men and 120mLmin for womenmdashwith considerable variation
bull CKD-EPI equation (estimated GFR in mLmin173m2) is most accurate
Age Gender RaceSCr
(mgdL) eGFR (mLmin173 m2)
20 M B 13 91
20 M W 13 75
55 M W 13 61
20 F W 13 56
55 F B 13 55
50 F W 13 46
B = black W = all ethnic groups other than blackWith evidence of kidney damage
(Duncan Heathcoat Djurdjev amp Levin 2001)(National Kidney Foundation 2002)
or lt 15 mLmin173m2
(Levey et al 2009)
True GFR could be gt 70 mLmin173m2
The ldquoerdquo in eGFR Stands for ldquoEstimatedrdquohellip
USE THESE EQUATIONS CAUTIOUSLY IF AT ALL IN hellip
bull Patients who haveare
bull Poor nutritionloss of muscle mass
bull Amputation
bull Chronic illness
bull Not African American or Caucasian
bull Changing serum creatinine
bull Obese
bull Very elderly young
(National Kidney Foundation 2014)
LAB ALBUMIN CREATININE RATIO
bull Urinary albumin-to-creatinine ratio (ACR) is calculated by dividing albumin concentration in milligrams by creatinine concentration in grams
bull Creatinine assists in adjusting albumin levels for varying urine concentrations which allows for more accurate results versus albumin alone
bull Spot urine albumin-to-creatinine ratio for quantification of proteinuria
bull New guidelines classify albuminuria as mild moderately or severely increased
bull First morning void preferable
bull 24hr urine test rarely necessary
THE NEW CKD CATEGORIES
STEPS TO CKD PATIENT CARE
1 CKD definition and risks2 Assess GFR albuminuria3 Determine etiology- what is going on here4 Slow progression5 Assess for associated complications6 Discuss dialysistransplantation
(Pal 2012)
KIDNEY INVOLVEMENT IN SYSTEMIC DISEASES
Hypertension
DiabetesAmyloidosis
Sickle cell diseases
Immune complex GN
Illicit drugs ndash cocaine heroin
Cholesterol emboli
HIV
Allergic reactions- drugsinterstitial nephritis
Hemolytic Uremic syndrome
Lupus
Systemic vasculitis
Liver FailureCongestive heart Failure
Image retrieved on 05 October 2010 from httpenwikipediaorgwikiFileGray1129pngThis image is under the public domain and not copyrightable in the US as per Bridgeman Art Library v Corel Corp
(Vasudev amp Vasudev 2012)
New CKD
Obtain ultrasound UA
microscopy albumincr ratio
Ultrasound shows
obstruction
bull Yes Relieve obstruction
bull No Is there albuminuria or glomerular bleeding (eval for glomerulo-nephritis
Fatehi amp Chi-yuan 2016
If red cells have their typical shape and color this indicates extra glomerular hematuria
Examples kidney stone disease UTI cystitis bleeding from collecting duct ureters bladder or urethra
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileReactive_lymphJPGCreative Commons License associated httpcreativecommonsorglicensesby-sa30deeden
(Vasudev amp Vasudev 2012)
DYSMORPHICRENAL HEMATURIA
bull This hematuria is characterized by bull a great variation in the size of the cells and by a high
percentage of dysmorphocytosiscasts (gt20)
bull Hematuria is usually related to glomerular bleeding bull It is typically accompanied by variable levels of albumuniuria
(Vasudev amp Vasudev 2012)
Urinary Cast Formation
Urine Microscopy can be helpful in work up of chronic kidney disease
In GNrsquos the red blood cells leak from the glomerulus into the tubules As they traverse through the tubules they can form cylindrical casts calledRBC casts
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileRedbloodcellsjpgThis image is a work of the National Institutes of Health part of the United States Department of Health and Human Services As a work of the US federal government the image is in the public domain
(Vasudev amp Vasudev 2012)
IF YOU HAVE ALBUMINURIA OR HEMATURIA-ORDER THE FOLLOWING LABS
Tests of autoimmunity Hepatitis serologies gt40 years- paraproteinassessment
ANA Hepatitis B serology (HBsAG)
Serum protein electrophoresis (SPEP)
RFanti-ccp Hepatitis C serology(HCV antibody)
Urine protein electrophoresis (UPEP)
Complement C3 C4
ANCANational Kidney Disease Education Program 2014 NIH
UPTODATE LAB RECOMENDATIONS
bull Lab to order cbc cmp urine albumincr ratio urine microscopy
bull Nephrotic pattern (protein gt35gday) ANA anti DS DNA C3 and C4 antibodies HIV HBV HCV serumurine immunofixation (amyloidosis) free light chain analysis (light chain deposition disease)
bull Nephritic pattern (red cells white cells casts variable protein) C3 C4 ANA dsDNA antineutrophil cytoplasmic antibody (ANCA) titers a streptozyme test HBV and HCV serologies HIV and in some cases blood cultures anti-glomerular basement membrane (GBM) antibodies and cryoglobulins
bull Renal biopsy(Hebert amp Parikh 2014)
EVALUATION OF NEW CKDNO OBSTRUCTION
NO EVIDENCE OF GLOMERULAR BLEEDING
High risk for multmyeloma (gt40
no nsaids no contrast
SPEP UPEP with immunofixation serum free light
chains
Evaluation depends on UA
Sterile pyuria
Eval for interstitial nephritis
Normal urinalysis
High risk for renovascular
disease
Eval for renovascular
disease
Follow serum creatinine-does it
remain stable(Fatehi amp Chi-yuan 2016)
POSSIBLE INVESTIGATIONShellip
Acute interstitial nephritisbull Drugs are the most common cause of AIN
DIABETIC NEPHROPATHY 1 CAUSE OF CKDbull Clinical syndromebull Albuminuria gt30 mg 24 hrsbull Proteinuria gt500 mg24 hrsbull Hypertension developsbull Progressive increase in proteinuriabull Progressive decline in glomerular filtration rate
bull Chronic kidney disease should be attributed to diabetic nephropathies in most patients with diabetes if albuminuria and diabetic retinopathy are both present other causes of CKD should be entertained if diabetic retinopathy is absent (KDIGO 2007)
DIABETIC NEPHROPATHY MORTALITY
bull After 40 yrs of DM
bull 10 alive if proteinuria is present
bull 70 alive if proteinuria is absent
bull Heart Disease is 15 times higher risk in those with proteinuria
bull Proteinuria = death in this population
Dunkler et al 2015
GOALS OF CARE IN CKD GLUCOSE CONTROL
bull Target HbA1c ~70 (lt695 greatest chance of reducing albuminuria)bull Can be extended above 70 with comorbidities or limited life expectancy and
risk of hypoglycemiabull Risk of hypoglycemia increases as kidney function becomes impairedbull Declining kidney function may necessitate changes to diabetes medications and
bull Just having HTN can cause proteinuriabull Usually 1-2 gms of protein a daybull Treat them like a diabetic with ACEI or ARBS and tight blood
pressure controlbull JNC-8 goal lt14090 for ptrsquos with CKDbull National kidney foundation lt14090 if ckd and no proteinuria
lt13080 if proteinuria present
(James Ortiz amp Et Al 2014)
TREATING HYPERTENSIONPROTEINURIA ACEI ORARBbull Riskbenefit should be carefully assessed in the elderly and medically fragilebull Check labs after initiation
bull If less than 30 SCr increase continue and monitorbull If more than 30 SCr increase stop ACEi and evaluate for renal artery stenosis
bull Continue until contraindication arises no absolute eGFR cutoffbull Better proteinuria suppression with low Na diet and diureticsbull Avoid volume depletionbull Avoid ACEi and ARB in combination12
bull Risk of adverse events (impaired kidney function hyperkalemia)
(Kunz Friedrich Wolbers amp Mann 2008)(Mann Schmieder amp McQueen 2008)
bull In adults gt50 yrs statin when eGFR ge 60 mlmin173m2 statin or statinezetimibe combination when eGFR lt 60 mlmin173m2
bull In adults lt 50 yrs statin if history of known CAD MI DM strokebull Aspirin is indicated for secondary but not primary prevention
Kidney Disease Improving Global Outcomes (KDIGO) CKD Work Group Kidney Int Suppls 201331-150
STATINS-RENOPROTECTIVECONTROVERSY
bull HMG-CoA reductase inhibitors (statins) in high doses can cause proteinuria
bull Possibly associated with less inflammation endothelial dysfunction and scarring in the kidney because they also block inflammatory cytokines
bull Use statins for CV disease not to treat proteinuria
(Afzali and Goldsmith 2016)
MEDICINE CAUTION
bull Hold metformin when gfr lt35 mlmin
bull GFR lt50 mlmin should alert to check all doses of meds
bull No bisphosphanates lt35 mlmin
bull No NSAIDScox 2 inhibitors lt60 mlmin
bull Atenolol ndashrenal excretion
bull BACTRIM A lot of AKI
MEDICINE CAUTION
bull Lovenox-use subcut heparinbull Apixibanbull Dabigatranbull Rivaroxibanbull Lithiumbull GABAPENTIN (ckd 4 max 300mg qd ckd 5 max 300mg qod)
STEPS TO CKD PATIENT CARE
1 CKD definition and risks2 Assess GFR albuminuria3 Determine etiology4 Assess for evidence of progression5 Assess for associated complications6 Discuss dialysistransplantation
CKD-CVD-DIABETES LINK CKD IS A DISEASE MULTIPLIER
National kidney foundation 2014
KDIGO 2017
CKD-MINERAL BONE DISORDERS
bull As kidneys fail they
bull Stop activating calcitriol (the active form of Vit D)mdashcausing calcium imbalance
bull Do not remove phosphorus from bloodmdashleading to phosphorus retention
bull The extra phosphorus pulls calcium out of bones causing them to weaken
bull High phosphorus stimulates PTH release
bull These changes (plus others) cause the start of secondary hyperparathyroidism
bull Labs
bull eGFR
bull Calcium
bull Phos
bull Vit D
bull iPTH
(Qunibi amp Henrich 2017)
PREVALENCE OF ABNORMALITIES OF MINERAL METABOLISM PTH IN CKD
bull Progression of disease ndash declining eGFR increasing proteinuria
bull Degree of proteinuria nephrotic syndrome gt 05-10 gd on ACEi or ARB therapy
bull Etiology of CKD not certain
bull Need help with disease management
bull Indications for kidney biopsy
Rosenberg 2016
WHEN TO REFER
STEPS TO CKD PATIENT CARE
1 CKD definition and risks2 Assess GFR albuminuria3 Determine etiology4 Assess for evidence of progression5 Assess for associated complications6 Discuss dialysistransplantation
KIDNEY TRANSPLANTATION
bull Treatment of choice for ESRDbull Improves quality of lifebull Waiting list time varies-3-5 yearsbull 3 year survival rate after transplantation is 83-94bull Increased risk of cancer
STARTING DIALYSIS IN THE ELDERLYhellipOR NOT
bull Among patients gt 75 yrs with stage 5 CKD who chose to NOT start dialysisbull Overall more likely to die over next 1-2 years bull But if they had ischemic heart disease or other significant comorbidity NO
DIFFERENCE in survival
bull Active disease management and supportive care may be appropriate without starting dialysis in the ill elderly
bull Palliative care does not mean ldquono carerdquo
bull Must have end-of-life discussions
(Murtagh et al 2007)
CKD MANAGEMENTbull Diagnose cause and treat underlying conditionbull Stage per guidelinesbull Slow progression of kidney disease (ACE inhibitors)bull Monitor for complicationsmdashvolume overload hyperkalemia metabolic acidosis
hyperphosphatemia anorexia fatigue htn bone diseasebull Labs cmp cbc phos Vit D 25OH iPTH urine microscopy uric acid urine
proteincr ratio-frequency based off heat map Get sono at least oncebull Vaccinate influenza hep B pneumococcalbull Eval ASCVD risk-likely needs statinbull Possible dexa (donrsquot give bisphosphonates if GFRlt35 let specialist manage)bull Refer to nephrology when eGFR is lt30 (sometimes if higher risk-refer earlier)
CASE 1
bull 55 year old man with past medical history of headaches presents to your office for his first time visit to a PCP in over 30 years
bull He has no past history of being admitted to the hospital and he does not take any OTC medsNSAIDsherbal meds He has no history of ETOH abuse smoking or drug use
bull Vitals BP 180100 mmHg pulse 80 R 18
bull Exam No JVD S1S2 regular PMI shifted to the left no gallop no abdominal bruit pulses bilaterally equal and regular no leg edema
bull What would you order
bull EKG cbc cmp ua urine proteincr ratio lipid
LAB RESULTS
bull Labs reveal a creatinine of 22 mgdL eGFR 33 Urine shows no blood or casts Urineprotein ratio shows 1 gm protein24 hrs EKG shows LVH
bull Next step in workupbull Renal ultrasound 1st then SPEP UPEP with immunofixation serum free light chains
bull Additional labs neg Renal ultrasound shows that both kidneys are slightly reduced in size and are mildly echogenic with no mass or hydronephrosis
bull What is your diagnosis
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileMain_complications_of_persistent_high_blood_pressurepngCreative Commons License associated httpcreativecommonsorglicensesby-sa30
bull 3 months Howevermdashwe have evidence of structural abnormalities Could potentially stage at G3b A3 (red on the heat map)
bull Goal blood pressure
bull JNC 8 14090 NKF 13080
bull Additional lab needed for progression monitoring
bull Cbc renal panel phos Vit D iPTH uric acid urine micro (we already have the renal sono and urine proteincr ratio and lipid)
Selective renal angiography (left lower renal artery) after successful percutaneous balloon dilatation of the stenotic lesionFibromuscular dysplasia in an accessory renal artery causing renovascular hypertension
Secondary Hypertension
Images retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileRenal_FMD2jpg and httpcommonswikimediaorgwikiFileRenal_FMDjpgCreative Commons License associated httpcreativecommonsorglicensesby20deeden (both images)
CASE 2bull OS is a 64year old Hispanic female in for DM check She has had DM for 15+ years and is currently
taking metformin 1000mg bid Lisinopril 10mg a day atorvastatin 40mg a day Labs today showed the following
bull Hgba1c 86 cmp eGFR 50 lipid WNL proteincr ratio 650mg These results are similar to her last visit
bull Upon further hx-you find that she had a recent eye exam and has mild nonproliferaive retinopathy She does not have neuropathy or other ss
bull What further workup do you need
bull Renal sonogram urine micro iPTH vit D (25 OH) phos uric acid
bull Dx stage
bull G3a A3
bull What further treatment do you need
bull Improve glycemic control Increase Lisinopril to 20mg with a goal of 40mg Avoid NSAIDs or other nephrotoxic agents make sure meds are renally dosed monitor 3xyear nephro referral
MANAGEMENT OF CKD IN DIABETESeGFR Recommended
All patients
Yearly measurement of creatinine urinary albumin excretion potassium
45-60 Referral to a nephrologist if possibility for nondiabetickidney disease existsConsider dose adjustment of medicationsMonitor eGFR every 6 monthsMonitor electrolytes bicarbonate hemoglobin calcium phosphorus parathyroid hormone at least yearly
Assure vitamin D sufficiencyConsider bone density testingReferral for dietary counselling
American Diabetes Association Standards of Medical Care in Diabetes Microvascular complications and foot care Diabetes Care 2017 40 (Suppl 1) S88-S98
CASE 3
bull 19 year old African American woman presents to your clinic with complaints of fatigue joint pains a new rash on her face oral ulcer
bull On exam BP 15080 P 88 Afebrile 96 O2 sats on RAbull GEN No respiratory distress at restbull HEENT painless oral ulcer flat rash over malar eminences sparing the nasolabial fold pallor +bull Lungs CTAbull CVS S1S2 regularbull Abdomen soft NTbull Ext left elbow joint and bilateral wrist joints are swollen and tender
bull What would you orderbull CBC CMP ua urine microscopy (microalbumin or urine proteincr ratio) ANA esr RF anti-ccp uric acid TSH
CASE 3
bull Working dx fatigue oral ulcer joint pain
bull Basic Labs Na 135 K 55 Bicarb 18 BUN 50 Cr 35 eGFR 22 Ca 90 ANA + titer 1640
bull UA 3+ blood 3+ protein RBC casts +
bull Given these results what is the most likely diagnosis
bull What would you do
SYSTEMIC LUPUS ERYTHEMATOSUS (SLE)
bull SLE multisystemic disease Etiology unknown
bull Production of autoantibodies and immune complexes formation
bull There is renal involvement in the great majority of patients with SLE at some time of the evolution 66-90
SLE ndash LUPUS NEPHRITIS
bull Race SLE is more commonsevere in African americans than Caucasiansbull
bull Gender female-to-male ratio of 91
bull Age Most patients develop lupus nephritis early in their disease course SLE is more common among women in the third decade of life and lupus nephritis occurs in patients aged 20-40 years
bull Kidney Biopsy For staging lupus nephritis (Class 1-5)
CASE 5bull A 80 year old man who has not seen a PCP in many years
presents to your clinic for weakness for the past few months On further questioning he tells you that his bones also have been hurting lately and he has developed leg swelling in the past month or so
bull On exam bull BP 16090 P 88 Afebrilebull GEN Thin built manbull HEENT pallor presentbull Lungs clearbull CVS S1S2 regular no rub or gallopbull Abdomen soft NTbull Ext 2 + edema
CASE 5
bull Differentials
bull CHF MI Cancer arthritis
bull Labs
bull CBC CMP urine microscopy urine proteincr ratio ESR TSH EKG BNP pa and lat CXR
bull LABS Urine dipstick negative for protein or blood
bull Basic chem bull Na 136 (135-145) K 51 (35-55) Chloride 108 (96-106) Bicarb 25
Given this presentation and the labs (low anion gap and elevated calcium anemia kidney failure) what will you think of What will you order next
Serum and urine protein electrophoresis
Intratubular refractile casts with surrounding syncytial giant cell reaction with chronic tubulointerstitial nephritis and fibrosis characteristic of myeloma cast nephropathy
Kidney Biopsy
CASE STUDYbull A 35 year old African American woman was seen in the clinic for
chronic cough and dyspnea on exertion She gave history of vague symptoms of fatigue and weight loss of 20 Ibs over the last six months
bull List some differentialsbull TB sarcoid lupus thyroid problems PEbull What would you orderbull PPD cbc cmp UA TSH ANA pa and lat cxr
bull Her labs were significant for mildly elevated calcium level and a creatinine of 20 mgdL eGFR 37
bull She had 750 mg of proteinuriaday
bull PPD neg ANA neg TSH and other labs WNL
bull Assuming this is present more than 3 monthshelliphellipwhat is her ckd stage
bull G3b A3
bull What do we still need
CT scan of chest
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileAnterior_mediastinal_mass_thymomajpgCreative Commons License associated httpcreativecommonsorglicensesby20deeden
CXR ndash HILAR LYMPHADENOPATHY
WHATS NEEDED NEXT
bull Biopsy of hilar lymphadenopathy or renal biopsy
bull DX sarcoidosis
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileSarcoidosis_signs_and_symptomsjpgThis work is in the public domain in the United States because it is a work of the United States Federal Government under the terms of Title 17 Chapter 1 Section 105 of the US Code
NEWLY DX CKD
bull 1) urinalysis microscopy ultrasound proteincr ratio
bull If obstruction-treat
bull No obstruction
bull Hx critical (consider myeloma if high risk)
bull glomerular bleeding or albumin in urine
bull Yes workup for glomerular causes (ANArf hep B C upep spep ANCA complement C3 C4)
bull No sterile pyruria-consider interstitial nephritis
bull High risk renovascular disease Evaluate renovascular disease
Additional Online Resources for CKD LearningbullNational Kidney Foundation wwwkidneyorgbullUnited States Renal Data Service wwwusrdsorgbullCDCrsquos CKD Surveillance Project
httpnccdcdcgovckdbullNational Kidney Disease Education Program
(NKDEP) httpnkdepnihgov
BIBLIOGRAPHY
bull Afzali B amp Goldsmith D J (2016 June 29) Statins and chronic kidney disease (G C Curhan amp A M Sheridan Eds) Retrieved 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsstatins-and-chronic-kidney-disease
bull American Diabetes Association Standards of Medical Care in Diabetes (2017) Microvascular complications and foot care Diabetes Care 2017 (40) S88-S98
bull American Diabetes Association Standards of Medical Care in Diabetes (2017) Microvascular complications and foot care Diabetes Care 40 (suppl 1) S88-S98
bull Berns J S (2017 Mar 22) Treatment of anemia in nondialysis chronic kidney disease (T A Golper amp A M Sheridan Eds) Retrieved from UpToDate httpswww-uptodate-comproxywichitaeducontentstreatment-of-anemia-in-nondialysis-chronic-kidney-disease
bull Chan M Dall A T Fletcher K E Lu N amp Trivedi H (2007) Outcomes in patients with chronic kidney disease referred late to nephrologists a meta-analysis American Journal of Medicine 120(12) 1063-1070
bull Coresh J Selvin E amp Stevens L A (2007) Prevalence of chronic kidny disease in the United States JAMA 298(17) doi101001jama298172038
bull de Brito-Ashurst I Varagunam M Raftery M amp Yagoob M (2009) Bicarbonate supplementation slows progression of CKD and improves nutritional status Journal of American Society of Nephrology (20) 2075-2084
BIBLIOGRAPHY
bull Duncan L Heathcoat J Djurdjev O amp Levin A (2001) Screening for renal disease using serum creatinine who are we missing Nephrology Dialysis and Transplant 16(5) 1042-1046
bull Dunkler D Gao P Lee S F Heinz G Clase C M Tobe S Oberbauer R (2015 August 7) Risk prediction for early CKD in type 2 diabetes Retrieved from Clinical Journal of the American Society of Nephrology httpcjasnasnjournalsorgcontent1081371fullsid=61422554-a5f1-41ac-b696-dcd3b12bd268
bull Fatehi P amp Chi-yuan H (September 15 2016) Diagnostic approach to the patient with newly identified chronic kidney disease (G C Curhan amp A M Sheridan Eds) Retrieved May 7 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsdiagnostic-approach-to-the-patient-with-newly-identified-chronic-kidney-disease
bull Fink J e (2009) Chronic Kidney Disease as an Under-Recognized Threat to Patient Safety American journal of kidney diseases the official journal of the National Kidney Foundation 53(4) 681-688
bull Gaffo A L amp Saag K G (2008 Nov) Management of hyperuricemia and gout in CKD doihttpdxdoiorg101053jajkd200807035
bull Hebert L A amp Parikh S V (2014 June 18) Differential diagnosis and evaluation of glomerular disease (R J Glassock amp A Q Lam Eds) Retrieved May 7 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsdifferential-diagnosis-and-evaluation-of-glomerular-disease
bull Inker L Perrone R D Sterns R H amp Forman J P (2017 March 7) Assessment of kidney function Retrieved from UpToDate httpswww-uptodate-comproxywichitaeducontentsassessment-of-kidney-functionsource=search_resultampsearch=creatinineampselectedTitle=1~150
BIBLIOGRAPHY
bull James P A Ortiz E amp Et Al (2014) Evidence based guideline for the management of high blood pressure in adults (JNC) JAMA 311(5) 507-520
bull Kidney Disease Improving Global Outcomes (KDIGO) CKD Work Group (2013 January) KDIGO 2012 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease Retrieved from Kidney International Supplement httpwwwkidney-internationalorg
bull Kunz R Friedrich C Wolbers M amp Mann J F (2008) Meta-analysis effect of monotherapy and combination therapy with inhibitors of the renin angiotensin system on proteinuria in renal disease Annals of Internal Medicine 148(1) 30-48
bull Levey A Stevens L A Schmid C H Castro A F Feldman H I Kusek J W Coresh J (2009) A new equation to estimate glomerular filtration rate Annals of Internal Medicine 150(9) 604-612
bull Levin A Bakris G L Molitch M Smulders M M Williams L A amp Andress D L (2007 Jan) Prevalence of abnormal serum vitamin D PTH calcium and phosphorus in patients with chronic kidney disease results of the study to evaluate early kidney disease Kidney International 71(1) 31-38 Retrieved from PubMED
bull Mahajan A Simoni J Sheather S Broglio K Rajab M amp Wesson D (2010) Daily oral sodium bicarbonate preserves glomerular filtration rate by slowing its decline in early hypertensive nephropathy Kidney International (78_ 303-309
bull Mann J Schmieder R E amp McQueen M (2008) Renal outcomes with telmisartan ramipril or both in people at high vascular risk (the ONTARGET study) a multicentre randomised doubleblind ocntrolled trial Lancet 372(9638) 547-533
BIBLIOGRAPHY
bull Matovinović M S (2009) Pathophysiology and classification of kidney disease Retrieved from The Journal of the International Federation of Clinical Chemistry and Laboratory Medicine httpwwwifccorgifccfilesdocs20010902pdf
bull Moe S Drueke T Lameire N amp Eknoyan G (2007 Jan) Chronic kidney disease-mineral-bone disorder a new paradigmdoi101053jackd200610005
bull Murtagh F E Marsh J E Donohoe P Ekbal N J Sheerin N S amp Harris F E (2007 July) Dialysis or not A comparative survival study of patients over 75 years with chronic kidney disease stage 5 Retrieved from Nephrology Dialysis and Transplant 22(7) httpswwwncbinlmnihgovpubmed17412702
bull National Kidney Foundation (2002) KDOQI clinical practice guidelines for chronic kidney disease evaluation classification andstratification American Journal of Kidney Disease S1-S266
bull National Kidney Foundation (2014 November 5) Fact Sheets Retrieved from httpwwwkidneyorgnewsnewsroomfactsheetsFastFacts
bull Pal S (2012 June 2) Trends in chronic kidney disease Retrieved from US Pharmacist (37)6 httpswwwuspharmacistcomarticletrends-in-chronic-kidney-disease
bull Qunibi W amp Henrich W L (2017 Jan 19) Overview of chronic kidney disease-mineral and bone disorder (J Berns amp A M Sheridan Eds) Retrieved from UpToDate httpswww-uptodate-comoverview-of-chronic-kidney-disease-mineral-and-bone-disorder-ckd-mbd
bull Rosenberg M (2016 Feb 24) Overview of the management of chronic kidney disease in adults (G C Curhan amp A M Sheridan Eds) Retrieved from UpToDate UpToDate httpswww-uptodate-comproxywichitaeducontentsoverview-of-the-management-of-chronic-kidney-disease-in-adults
BIBLIOGRAPHY
bull Szczech L Stewart R C Hsu-Lin S DeLosky R J Astor B C Fox C H Vassalotti J A (2014) Primary care detection of chronic kidney disease in adults with type 2 diabetes The ADD-CKD Study (Awareness Detection and Drug Therapy in type 2 diabetes and chronic kidney disease PLOS doihttpsdoiorg101371journalpone0110535
bull USRDS (2016) Annual data report 2016 Epidemiology of kidney disease in the United States Retrieved from United States Renal Data System httpswwwusrdsorgadraspx
bull Vasudev B amp Vasudev M (2012) A model curriculum for residents rotating in nephrology MedEDPORTAL doihttpdoiorg1015766mep_2374-82658288
bull Wei L MacDonald T M Jennings C Sheng X amp Flynn R W (2013) Estimated GFR reporting is associated with decreased nonsteroidal anti-inflammatory drug prescribing and increased renal function Kidney International (84)1 174-178
chronic kidney disease in primary care
CKD as a Public Health Issue
Slide Number 3
Costs of CKD in 2013 dollarsUSRDS report
Steps to CKD Patient Care
Renal anatomy and physiology
Definition of Chronic Kidney Disease
CKD Risk Factors
Gaps in CKD Diagnosis
Slide Number 10
Steps to CKD Patient Care
creatinine
Glomerular filtration rate
Slide Number 14
Slide Number 15
Use These Equations Cautiously if at all in hellip
lab albumin creatinine ratio
The New CKD Categories
Steps to CKD Patient Care
Slide Number 20
Kidney Involvement in Systemic Diseases
Slide Number 22
Slide Number 23
DysmorphicRenal Hematuria
Slide Number 25
If you have albuminuria or hematuria-order the following labs
Prevalence of Abnormalities of Mineral Metabolism PTH in CKD
Managing CKD-MBD complications
CKD-MBD Testing
Anemia Becomes More Common as Kidney Function Declines
Detect and Manage CKD Complications
Complications-metabolic acidosis
Complications-vascular calcification
Hyperkalemia management
Hyperuricemia levels amp CKD
CKD monitoring levels 345
Slide Number 59
When to Refer to a Nephrologist
When to Refer
Steps to CKD Patient Care
Kidney transplantation
Starting Dialysis in the ElderlyhellipOr Not
Ckd management
Case 1
Slide Number 67
Lab results
Slide Number 69
Hypertensive nephropathy with proteinuria
Slide Number 71
Case 2
Slide Number 73
Management of CKD in Diabetes
Case 3
Case 3
Systemic Lupus Erythematosus (SLE)
SLE ndash Lupus Nephritis
Case 5
Case 5
Slide Number 81
Slide Number 82
Case study
Slide Number 84
CXR ndash Hilar Lymphadenopathy
Whats needed next
Slide Number 87
newly dx ckd
Slide Number 89
Bibliography
bibliography
bibliography
bibliography
bibliography
Stage 12
Stage 3
Stage 4
Stage 5
Hb le10 gdL
52
56
11
272
Hb gt10-le12 gdL
216
359
426
483
Hb le12 gdL
267
416
536
755
Stage 12
Stage 3
Stage 4
Stage 5
DEFINITION OF CHRONIC KIDNEY DISEASE
bull Kidney damage for gt 3 months
bull Structural or functional abnormalities of the kidneys with our without decreased GFR manifest by either
bull Pathological abnormalities
bull Markers of kidney damage including abnormalities in the composition of the blood or urine or in imaging tests
bull GFR lt 60 mlmin173 m2 for gt 3 months with or without kidney damage as defined above
(Kidney Disease Improving Global Outcomes (KDIGO) CKD Work Group 2013)
CKD RISK FACTORS
Modifiablebull Diabetesbull Hypertensionbull History of AKIbull Frequent NSAID use
bull Obesity
bull Hyperuricemia
bull Smoking
bull Sedentary lifestyle
bull Dietary Protein Intake
Non-modifiablebull Family history of kidney disease diabetes or
hypertension
bull Age 60 or older (GFR declines normally with age)
bull RaceUS ethnic minority status
Partial listAKI acute kidney injury (Kidney Disease Improving Global Outcomes (KDIGO) CKD Work Group 2013)
GAPS IN CKD DIAGNOSIS
Szczech Lynda A et al Primary Care Detection of Chronic Kidney Disease in Adults with Type-2 Diabetes The ADD-CKD Study (Awareness Detection and Drug Therapy in Type-2 Diabetes and Chronic Kidney Disease) PLOS One - In press (2014)
0
10
20
30
40
50
60
Not Appropriately Tested Appropriately tested - no diagnosis Appropriately tested - accurate diagnosis
CKD Screening in Primary Care( of patients)
of Patients
Improved Diagnosishellip
Studies demonstrate that clinician behavior changes when CKD diagnosis improves Significant improvements realized in1-3
bull Increased urinary albumin testingbull Increased appropriate use of ACEi or ARBbull Avoidance of NSAIDs prescribing among patients
with low eGFRbull Appropriate nephrology consultation
1 Wei L et al Kidney Int 201384174-1782 Chan M et al Am J Med 20071201063-10703 Fink J et al Am J Kidney Dis 200953681-668
STEPS TO CKD PATIENT CARE
1 CKD definition and risks2 Assess GFR albuminuria (knowing the labs)3 Determine etiology4 Slow progression5 Assess for associated complications6 Discuss dialysistransplantation
CREATININEbull Creatinine is derived from the metabolism of creatine in skeletal
muscle and from dietary meat intake
creatinine secretion by the renal tubules + creatine intake (ie diet)+ creatinine pool size (ie muscle mass) all remain constant
bull GFR is equal to the sum of the filtration rates in all of the functioning nephrons
bull Glomeruli filter 180Lday (125mLmin) of plasma
bull Normal GFR depends on age sex body size and is approximately 130mLmin for men and 120mLmin for womenmdashwith considerable variation
bull CKD-EPI equation (estimated GFR in mLmin173m2) is most accurate
Age Gender RaceSCr
(mgdL) eGFR (mLmin173 m2)
20 M B 13 91
20 M W 13 75
55 M W 13 61
20 F W 13 56
55 F B 13 55
50 F W 13 46
B = black W = all ethnic groups other than blackWith evidence of kidney damage
(Duncan Heathcoat Djurdjev amp Levin 2001)(National Kidney Foundation 2002)
or lt 15 mLmin173m2
(Levey et al 2009)
True GFR could be gt 70 mLmin173m2
The ldquoerdquo in eGFR Stands for ldquoEstimatedrdquohellip
USE THESE EQUATIONS CAUTIOUSLY IF AT ALL IN hellip
bull Patients who haveare
bull Poor nutritionloss of muscle mass
bull Amputation
bull Chronic illness
bull Not African American or Caucasian
bull Changing serum creatinine
bull Obese
bull Very elderly young
(National Kidney Foundation 2014)
LAB ALBUMIN CREATININE RATIO
bull Urinary albumin-to-creatinine ratio (ACR) is calculated by dividing albumin concentration in milligrams by creatinine concentration in grams
bull Creatinine assists in adjusting albumin levels for varying urine concentrations which allows for more accurate results versus albumin alone
bull Spot urine albumin-to-creatinine ratio for quantification of proteinuria
bull New guidelines classify albuminuria as mild moderately or severely increased
bull First morning void preferable
bull 24hr urine test rarely necessary
THE NEW CKD CATEGORIES
STEPS TO CKD PATIENT CARE
1 CKD definition and risks2 Assess GFR albuminuria3 Determine etiology- what is going on here4 Slow progression5 Assess for associated complications6 Discuss dialysistransplantation
(Pal 2012)
KIDNEY INVOLVEMENT IN SYSTEMIC DISEASES
Hypertension
DiabetesAmyloidosis
Sickle cell diseases
Immune complex GN
Illicit drugs ndash cocaine heroin
Cholesterol emboli
HIV
Allergic reactions- drugsinterstitial nephritis
Hemolytic Uremic syndrome
Lupus
Systemic vasculitis
Liver FailureCongestive heart Failure
Image retrieved on 05 October 2010 from httpenwikipediaorgwikiFileGray1129pngThis image is under the public domain and not copyrightable in the US as per Bridgeman Art Library v Corel Corp
(Vasudev amp Vasudev 2012)
New CKD
Obtain ultrasound UA
microscopy albumincr ratio
Ultrasound shows
obstruction
bull Yes Relieve obstruction
bull No Is there albuminuria or glomerular bleeding (eval for glomerulo-nephritis
Fatehi amp Chi-yuan 2016
If red cells have their typical shape and color this indicates extra glomerular hematuria
Examples kidney stone disease UTI cystitis bleeding from collecting duct ureters bladder or urethra
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileReactive_lymphJPGCreative Commons License associated httpcreativecommonsorglicensesby-sa30deeden
(Vasudev amp Vasudev 2012)
DYSMORPHICRENAL HEMATURIA
bull This hematuria is characterized by bull a great variation in the size of the cells and by a high
percentage of dysmorphocytosiscasts (gt20)
bull Hematuria is usually related to glomerular bleeding bull It is typically accompanied by variable levels of albumuniuria
(Vasudev amp Vasudev 2012)
Urinary Cast Formation
Urine Microscopy can be helpful in work up of chronic kidney disease
In GNrsquos the red blood cells leak from the glomerulus into the tubules As they traverse through the tubules they can form cylindrical casts calledRBC casts
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileRedbloodcellsjpgThis image is a work of the National Institutes of Health part of the United States Department of Health and Human Services As a work of the US federal government the image is in the public domain
(Vasudev amp Vasudev 2012)
IF YOU HAVE ALBUMINURIA OR HEMATURIA-ORDER THE FOLLOWING LABS
Tests of autoimmunity Hepatitis serologies gt40 years- paraproteinassessment
ANA Hepatitis B serology (HBsAG)
Serum protein electrophoresis (SPEP)
RFanti-ccp Hepatitis C serology(HCV antibody)
Urine protein electrophoresis (UPEP)
Complement C3 C4
ANCANational Kidney Disease Education Program 2014 NIH
UPTODATE LAB RECOMENDATIONS
bull Lab to order cbc cmp urine albumincr ratio urine microscopy
bull Nephrotic pattern (protein gt35gday) ANA anti DS DNA C3 and C4 antibodies HIV HBV HCV serumurine immunofixation (amyloidosis) free light chain analysis (light chain deposition disease)
bull Nephritic pattern (red cells white cells casts variable protein) C3 C4 ANA dsDNA antineutrophil cytoplasmic antibody (ANCA) titers a streptozyme test HBV and HCV serologies HIV and in some cases blood cultures anti-glomerular basement membrane (GBM) antibodies and cryoglobulins
bull Renal biopsy(Hebert amp Parikh 2014)
EVALUATION OF NEW CKDNO OBSTRUCTION
NO EVIDENCE OF GLOMERULAR BLEEDING
High risk for multmyeloma (gt40
no nsaids no contrast
SPEP UPEP with immunofixation serum free light
chains
Evaluation depends on UA
Sterile pyuria
Eval for interstitial nephritis
Normal urinalysis
High risk for renovascular
disease
Eval for renovascular
disease
Follow serum creatinine-does it
remain stable(Fatehi amp Chi-yuan 2016)
POSSIBLE INVESTIGATIONShellip
Acute interstitial nephritisbull Drugs are the most common cause of AIN
DIABETIC NEPHROPATHY 1 CAUSE OF CKDbull Clinical syndromebull Albuminuria gt30 mg 24 hrsbull Proteinuria gt500 mg24 hrsbull Hypertension developsbull Progressive increase in proteinuriabull Progressive decline in glomerular filtration rate
bull Chronic kidney disease should be attributed to diabetic nephropathies in most patients with diabetes if albuminuria and diabetic retinopathy are both present other causes of CKD should be entertained if diabetic retinopathy is absent (KDIGO 2007)
DIABETIC NEPHROPATHY MORTALITY
bull After 40 yrs of DM
bull 10 alive if proteinuria is present
bull 70 alive if proteinuria is absent
bull Heart Disease is 15 times higher risk in those with proteinuria
bull Proteinuria = death in this population
Dunkler et al 2015
GOALS OF CARE IN CKD GLUCOSE CONTROL
bull Target HbA1c ~70 (lt695 greatest chance of reducing albuminuria)bull Can be extended above 70 with comorbidities or limited life expectancy and
risk of hypoglycemiabull Risk of hypoglycemia increases as kidney function becomes impairedbull Declining kidney function may necessitate changes to diabetes medications and
bull Just having HTN can cause proteinuriabull Usually 1-2 gms of protein a daybull Treat them like a diabetic with ACEI or ARBS and tight blood
pressure controlbull JNC-8 goal lt14090 for ptrsquos with CKDbull National kidney foundation lt14090 if ckd and no proteinuria
lt13080 if proteinuria present
(James Ortiz amp Et Al 2014)
TREATING HYPERTENSIONPROTEINURIA ACEI ORARBbull Riskbenefit should be carefully assessed in the elderly and medically fragilebull Check labs after initiation
bull If less than 30 SCr increase continue and monitorbull If more than 30 SCr increase stop ACEi and evaluate for renal artery stenosis
bull Continue until contraindication arises no absolute eGFR cutoffbull Better proteinuria suppression with low Na diet and diureticsbull Avoid volume depletionbull Avoid ACEi and ARB in combination12
bull Risk of adverse events (impaired kidney function hyperkalemia)
(Kunz Friedrich Wolbers amp Mann 2008)(Mann Schmieder amp McQueen 2008)
bull In adults gt50 yrs statin when eGFR ge 60 mlmin173m2 statin or statinezetimibe combination when eGFR lt 60 mlmin173m2
bull In adults lt 50 yrs statin if history of known CAD MI DM strokebull Aspirin is indicated for secondary but not primary prevention
Kidney Disease Improving Global Outcomes (KDIGO) CKD Work Group Kidney Int Suppls 201331-150
STATINS-RENOPROTECTIVECONTROVERSY
bull HMG-CoA reductase inhibitors (statins) in high doses can cause proteinuria
bull Possibly associated with less inflammation endothelial dysfunction and scarring in the kidney because they also block inflammatory cytokines
bull Use statins for CV disease not to treat proteinuria
(Afzali and Goldsmith 2016)
MEDICINE CAUTION
bull Hold metformin when gfr lt35 mlmin
bull GFR lt50 mlmin should alert to check all doses of meds
bull No bisphosphanates lt35 mlmin
bull No NSAIDScox 2 inhibitors lt60 mlmin
bull Atenolol ndashrenal excretion
bull BACTRIM A lot of AKI
MEDICINE CAUTION
bull Lovenox-use subcut heparinbull Apixibanbull Dabigatranbull Rivaroxibanbull Lithiumbull GABAPENTIN (ckd 4 max 300mg qd ckd 5 max 300mg qod)
STEPS TO CKD PATIENT CARE
1 CKD definition and risks2 Assess GFR albuminuria3 Determine etiology4 Assess for evidence of progression5 Assess for associated complications6 Discuss dialysistransplantation
CKD-CVD-DIABETES LINK CKD IS A DISEASE MULTIPLIER
National kidney foundation 2014
KDIGO 2017
CKD-MINERAL BONE DISORDERS
bull As kidneys fail they
bull Stop activating calcitriol (the active form of Vit D)mdashcausing calcium imbalance
bull Do not remove phosphorus from bloodmdashleading to phosphorus retention
bull The extra phosphorus pulls calcium out of bones causing them to weaken
bull High phosphorus stimulates PTH release
bull These changes (plus others) cause the start of secondary hyperparathyroidism
bull Labs
bull eGFR
bull Calcium
bull Phos
bull Vit D
bull iPTH
(Qunibi amp Henrich 2017)
PREVALENCE OF ABNORMALITIES OF MINERAL METABOLISM PTH IN CKD
bull Progression of disease ndash declining eGFR increasing proteinuria
bull Degree of proteinuria nephrotic syndrome gt 05-10 gd on ACEi or ARB therapy
bull Etiology of CKD not certain
bull Need help with disease management
bull Indications for kidney biopsy
Rosenberg 2016
WHEN TO REFER
STEPS TO CKD PATIENT CARE
1 CKD definition and risks2 Assess GFR albuminuria3 Determine etiology4 Assess for evidence of progression5 Assess for associated complications6 Discuss dialysistransplantation
KIDNEY TRANSPLANTATION
bull Treatment of choice for ESRDbull Improves quality of lifebull Waiting list time varies-3-5 yearsbull 3 year survival rate after transplantation is 83-94bull Increased risk of cancer
STARTING DIALYSIS IN THE ELDERLYhellipOR NOT
bull Among patients gt 75 yrs with stage 5 CKD who chose to NOT start dialysisbull Overall more likely to die over next 1-2 years bull But if they had ischemic heart disease or other significant comorbidity NO
DIFFERENCE in survival
bull Active disease management and supportive care may be appropriate without starting dialysis in the ill elderly
bull Palliative care does not mean ldquono carerdquo
bull Must have end-of-life discussions
(Murtagh et al 2007)
CKD MANAGEMENTbull Diagnose cause and treat underlying conditionbull Stage per guidelinesbull Slow progression of kidney disease (ACE inhibitors)bull Monitor for complicationsmdashvolume overload hyperkalemia metabolic acidosis
hyperphosphatemia anorexia fatigue htn bone diseasebull Labs cmp cbc phos Vit D 25OH iPTH urine microscopy uric acid urine
proteincr ratio-frequency based off heat map Get sono at least oncebull Vaccinate influenza hep B pneumococcalbull Eval ASCVD risk-likely needs statinbull Possible dexa (donrsquot give bisphosphonates if GFRlt35 let specialist manage)bull Refer to nephrology when eGFR is lt30 (sometimes if higher risk-refer earlier)
CASE 1
bull 55 year old man with past medical history of headaches presents to your office for his first time visit to a PCP in over 30 years
bull He has no past history of being admitted to the hospital and he does not take any OTC medsNSAIDsherbal meds He has no history of ETOH abuse smoking or drug use
bull Vitals BP 180100 mmHg pulse 80 R 18
bull Exam No JVD S1S2 regular PMI shifted to the left no gallop no abdominal bruit pulses bilaterally equal and regular no leg edema
bull What would you order
bull EKG cbc cmp ua urine proteincr ratio lipid
LAB RESULTS
bull Labs reveal a creatinine of 22 mgdL eGFR 33 Urine shows no blood or casts Urineprotein ratio shows 1 gm protein24 hrs EKG shows LVH
bull Next step in workupbull Renal ultrasound 1st then SPEP UPEP with immunofixation serum free light chains
bull Additional labs neg Renal ultrasound shows that both kidneys are slightly reduced in size and are mildly echogenic with no mass or hydronephrosis
bull What is your diagnosis
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileMain_complications_of_persistent_high_blood_pressurepngCreative Commons License associated httpcreativecommonsorglicensesby-sa30
bull 3 months Howevermdashwe have evidence of structural abnormalities Could potentially stage at G3b A3 (red on the heat map)
bull Goal blood pressure
bull JNC 8 14090 NKF 13080
bull Additional lab needed for progression monitoring
bull Cbc renal panel phos Vit D iPTH uric acid urine micro (we already have the renal sono and urine proteincr ratio and lipid)
Selective renal angiography (left lower renal artery) after successful percutaneous balloon dilatation of the stenotic lesionFibromuscular dysplasia in an accessory renal artery causing renovascular hypertension
Secondary Hypertension
Images retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileRenal_FMD2jpg and httpcommonswikimediaorgwikiFileRenal_FMDjpgCreative Commons License associated httpcreativecommonsorglicensesby20deeden (both images)
CASE 2bull OS is a 64year old Hispanic female in for DM check She has had DM for 15+ years and is currently
taking metformin 1000mg bid Lisinopril 10mg a day atorvastatin 40mg a day Labs today showed the following
bull Hgba1c 86 cmp eGFR 50 lipid WNL proteincr ratio 650mg These results are similar to her last visit
bull Upon further hx-you find that she had a recent eye exam and has mild nonproliferaive retinopathy She does not have neuropathy or other ss
bull What further workup do you need
bull Renal sonogram urine micro iPTH vit D (25 OH) phos uric acid
bull Dx stage
bull G3a A3
bull What further treatment do you need
bull Improve glycemic control Increase Lisinopril to 20mg with a goal of 40mg Avoid NSAIDs or other nephrotoxic agents make sure meds are renally dosed monitor 3xyear nephro referral
MANAGEMENT OF CKD IN DIABETESeGFR Recommended
All patients
Yearly measurement of creatinine urinary albumin excretion potassium
45-60 Referral to a nephrologist if possibility for nondiabetickidney disease existsConsider dose adjustment of medicationsMonitor eGFR every 6 monthsMonitor electrolytes bicarbonate hemoglobin calcium phosphorus parathyroid hormone at least yearly
Assure vitamin D sufficiencyConsider bone density testingReferral for dietary counselling
American Diabetes Association Standards of Medical Care in Diabetes Microvascular complications and foot care Diabetes Care 2017 40 (Suppl 1) S88-S98
CASE 3
bull 19 year old African American woman presents to your clinic with complaints of fatigue joint pains a new rash on her face oral ulcer
bull On exam BP 15080 P 88 Afebrile 96 O2 sats on RAbull GEN No respiratory distress at restbull HEENT painless oral ulcer flat rash over malar eminences sparing the nasolabial fold pallor +bull Lungs CTAbull CVS S1S2 regularbull Abdomen soft NTbull Ext left elbow joint and bilateral wrist joints are swollen and tender
bull What would you orderbull CBC CMP ua urine microscopy (microalbumin or urine proteincr ratio) ANA esr RF anti-ccp uric acid TSH
CASE 3
bull Working dx fatigue oral ulcer joint pain
bull Basic Labs Na 135 K 55 Bicarb 18 BUN 50 Cr 35 eGFR 22 Ca 90 ANA + titer 1640
bull UA 3+ blood 3+ protein RBC casts +
bull Given these results what is the most likely diagnosis
bull What would you do
SYSTEMIC LUPUS ERYTHEMATOSUS (SLE)
bull SLE multisystemic disease Etiology unknown
bull Production of autoantibodies and immune complexes formation
bull There is renal involvement in the great majority of patients with SLE at some time of the evolution 66-90
SLE ndash LUPUS NEPHRITIS
bull Race SLE is more commonsevere in African americans than Caucasiansbull
bull Gender female-to-male ratio of 91
bull Age Most patients develop lupus nephritis early in their disease course SLE is more common among women in the third decade of life and lupus nephritis occurs in patients aged 20-40 years
bull Kidney Biopsy For staging lupus nephritis (Class 1-5)
CASE 5bull A 80 year old man who has not seen a PCP in many years
presents to your clinic for weakness for the past few months On further questioning he tells you that his bones also have been hurting lately and he has developed leg swelling in the past month or so
bull On exam bull BP 16090 P 88 Afebrilebull GEN Thin built manbull HEENT pallor presentbull Lungs clearbull CVS S1S2 regular no rub or gallopbull Abdomen soft NTbull Ext 2 + edema
CASE 5
bull Differentials
bull CHF MI Cancer arthritis
bull Labs
bull CBC CMP urine microscopy urine proteincr ratio ESR TSH EKG BNP pa and lat CXR
bull LABS Urine dipstick negative for protein or blood
bull Basic chem bull Na 136 (135-145) K 51 (35-55) Chloride 108 (96-106) Bicarb 25
Given this presentation and the labs (low anion gap and elevated calcium anemia kidney failure) what will you think of What will you order next
Serum and urine protein electrophoresis
Intratubular refractile casts with surrounding syncytial giant cell reaction with chronic tubulointerstitial nephritis and fibrosis characteristic of myeloma cast nephropathy
Kidney Biopsy
CASE STUDYbull A 35 year old African American woman was seen in the clinic for
chronic cough and dyspnea on exertion She gave history of vague symptoms of fatigue and weight loss of 20 Ibs over the last six months
bull List some differentialsbull TB sarcoid lupus thyroid problems PEbull What would you orderbull PPD cbc cmp UA TSH ANA pa and lat cxr
bull Her labs were significant for mildly elevated calcium level and a creatinine of 20 mgdL eGFR 37
bull She had 750 mg of proteinuriaday
bull PPD neg ANA neg TSH and other labs WNL
bull Assuming this is present more than 3 monthshelliphellipwhat is her ckd stage
bull G3b A3
bull What do we still need
CT scan of chest
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileAnterior_mediastinal_mass_thymomajpgCreative Commons License associated httpcreativecommonsorglicensesby20deeden
CXR ndash HILAR LYMPHADENOPATHY
WHATS NEEDED NEXT
bull Biopsy of hilar lymphadenopathy or renal biopsy
bull DX sarcoidosis
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileSarcoidosis_signs_and_symptomsjpgThis work is in the public domain in the United States because it is a work of the United States Federal Government under the terms of Title 17 Chapter 1 Section 105 of the US Code
NEWLY DX CKD
bull 1) urinalysis microscopy ultrasound proteincr ratio
bull If obstruction-treat
bull No obstruction
bull Hx critical (consider myeloma if high risk)
bull glomerular bleeding or albumin in urine
bull Yes workup for glomerular causes (ANArf hep B C upep spep ANCA complement C3 C4)
bull No sterile pyruria-consider interstitial nephritis
bull High risk renovascular disease Evaluate renovascular disease
Additional Online Resources for CKD LearningbullNational Kidney Foundation wwwkidneyorgbullUnited States Renal Data Service wwwusrdsorgbullCDCrsquos CKD Surveillance Project
httpnccdcdcgovckdbullNational Kidney Disease Education Program
(NKDEP) httpnkdepnihgov
BIBLIOGRAPHY
bull Afzali B amp Goldsmith D J (2016 June 29) Statins and chronic kidney disease (G C Curhan amp A M Sheridan Eds) Retrieved 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsstatins-and-chronic-kidney-disease
bull American Diabetes Association Standards of Medical Care in Diabetes (2017) Microvascular complications and foot care Diabetes Care 2017 (40) S88-S98
bull American Diabetes Association Standards of Medical Care in Diabetes (2017) Microvascular complications and foot care Diabetes Care 40 (suppl 1) S88-S98
bull Berns J S (2017 Mar 22) Treatment of anemia in nondialysis chronic kidney disease (T A Golper amp A M Sheridan Eds) Retrieved from UpToDate httpswww-uptodate-comproxywichitaeducontentstreatment-of-anemia-in-nondialysis-chronic-kidney-disease
bull Chan M Dall A T Fletcher K E Lu N amp Trivedi H (2007) Outcomes in patients with chronic kidney disease referred late to nephrologists a meta-analysis American Journal of Medicine 120(12) 1063-1070
bull Coresh J Selvin E amp Stevens L A (2007) Prevalence of chronic kidny disease in the United States JAMA 298(17) doi101001jama298172038
bull de Brito-Ashurst I Varagunam M Raftery M amp Yagoob M (2009) Bicarbonate supplementation slows progression of CKD and improves nutritional status Journal of American Society of Nephrology (20) 2075-2084
BIBLIOGRAPHY
bull Duncan L Heathcoat J Djurdjev O amp Levin A (2001) Screening for renal disease using serum creatinine who are we missing Nephrology Dialysis and Transplant 16(5) 1042-1046
bull Dunkler D Gao P Lee S F Heinz G Clase C M Tobe S Oberbauer R (2015 August 7) Risk prediction for early CKD in type 2 diabetes Retrieved from Clinical Journal of the American Society of Nephrology httpcjasnasnjournalsorgcontent1081371fullsid=61422554-a5f1-41ac-b696-dcd3b12bd268
bull Fatehi P amp Chi-yuan H (September 15 2016) Diagnostic approach to the patient with newly identified chronic kidney disease (G C Curhan amp A M Sheridan Eds) Retrieved May 7 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsdiagnostic-approach-to-the-patient-with-newly-identified-chronic-kidney-disease
bull Fink J e (2009) Chronic Kidney Disease as an Under-Recognized Threat to Patient Safety American journal of kidney diseases the official journal of the National Kidney Foundation 53(4) 681-688
bull Gaffo A L amp Saag K G (2008 Nov) Management of hyperuricemia and gout in CKD doihttpdxdoiorg101053jajkd200807035
bull Hebert L A amp Parikh S V (2014 June 18) Differential diagnosis and evaluation of glomerular disease (R J Glassock amp A Q Lam Eds) Retrieved May 7 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsdifferential-diagnosis-and-evaluation-of-glomerular-disease
bull Inker L Perrone R D Sterns R H amp Forman J P (2017 March 7) Assessment of kidney function Retrieved from UpToDate httpswww-uptodate-comproxywichitaeducontentsassessment-of-kidney-functionsource=search_resultampsearch=creatinineampselectedTitle=1~150
BIBLIOGRAPHY
bull James P A Ortiz E amp Et Al (2014) Evidence based guideline for the management of high blood pressure in adults (JNC) JAMA 311(5) 507-520
bull Kidney Disease Improving Global Outcomes (KDIGO) CKD Work Group (2013 January) KDIGO 2012 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease Retrieved from Kidney International Supplement httpwwwkidney-internationalorg
bull Kunz R Friedrich C Wolbers M amp Mann J F (2008) Meta-analysis effect of monotherapy and combination therapy with inhibitors of the renin angiotensin system on proteinuria in renal disease Annals of Internal Medicine 148(1) 30-48
bull Levey A Stevens L A Schmid C H Castro A F Feldman H I Kusek J W Coresh J (2009) A new equation to estimate glomerular filtration rate Annals of Internal Medicine 150(9) 604-612
bull Levin A Bakris G L Molitch M Smulders M M Williams L A amp Andress D L (2007 Jan) Prevalence of abnormal serum vitamin D PTH calcium and phosphorus in patients with chronic kidney disease results of the study to evaluate early kidney disease Kidney International 71(1) 31-38 Retrieved from PubMED
bull Mahajan A Simoni J Sheather S Broglio K Rajab M amp Wesson D (2010) Daily oral sodium bicarbonate preserves glomerular filtration rate by slowing its decline in early hypertensive nephropathy Kidney International (78_ 303-309
bull Mann J Schmieder R E amp McQueen M (2008) Renal outcomes with telmisartan ramipril or both in people at high vascular risk (the ONTARGET study) a multicentre randomised doubleblind ocntrolled trial Lancet 372(9638) 547-533
BIBLIOGRAPHY
bull Matovinović M S (2009) Pathophysiology and classification of kidney disease Retrieved from The Journal of the International Federation of Clinical Chemistry and Laboratory Medicine httpwwwifccorgifccfilesdocs20010902pdf
bull Moe S Drueke T Lameire N amp Eknoyan G (2007 Jan) Chronic kidney disease-mineral-bone disorder a new paradigmdoi101053jackd200610005
bull Murtagh F E Marsh J E Donohoe P Ekbal N J Sheerin N S amp Harris F E (2007 July) Dialysis or not A comparative survival study of patients over 75 years with chronic kidney disease stage 5 Retrieved from Nephrology Dialysis and Transplant 22(7) httpswwwncbinlmnihgovpubmed17412702
bull National Kidney Foundation (2002) KDOQI clinical practice guidelines for chronic kidney disease evaluation classification andstratification American Journal of Kidney Disease S1-S266
bull National Kidney Foundation (2014 November 5) Fact Sheets Retrieved from httpwwwkidneyorgnewsnewsroomfactsheetsFastFacts
bull Pal S (2012 June 2) Trends in chronic kidney disease Retrieved from US Pharmacist (37)6 httpswwwuspharmacistcomarticletrends-in-chronic-kidney-disease
bull Qunibi W amp Henrich W L (2017 Jan 19) Overview of chronic kidney disease-mineral and bone disorder (J Berns amp A M Sheridan Eds) Retrieved from UpToDate httpswww-uptodate-comoverview-of-chronic-kidney-disease-mineral-and-bone-disorder-ckd-mbd
bull Rosenberg M (2016 Feb 24) Overview of the management of chronic kidney disease in adults (G C Curhan amp A M Sheridan Eds) Retrieved from UpToDate UpToDate httpswww-uptodate-comproxywichitaeducontentsoverview-of-the-management-of-chronic-kidney-disease-in-adults
BIBLIOGRAPHY
bull Szczech L Stewart R C Hsu-Lin S DeLosky R J Astor B C Fox C H Vassalotti J A (2014) Primary care detection of chronic kidney disease in adults with type 2 diabetes The ADD-CKD Study (Awareness Detection and Drug Therapy in type 2 diabetes and chronic kidney disease PLOS doihttpsdoiorg101371journalpone0110535
bull USRDS (2016) Annual data report 2016 Epidemiology of kidney disease in the United States Retrieved from United States Renal Data System httpswwwusrdsorgadraspx
bull Vasudev B amp Vasudev M (2012) A model curriculum for residents rotating in nephrology MedEDPORTAL doihttpdoiorg1015766mep_2374-82658288
bull Wei L MacDonald T M Jennings C Sheng X amp Flynn R W (2013) Estimated GFR reporting is associated with decreased nonsteroidal anti-inflammatory drug prescribing and increased renal function Kidney International (84)1 174-178
chronic kidney disease in primary care
CKD as a Public Health Issue
Slide Number 3
Costs of CKD in 2013 dollarsUSRDS report
Steps to CKD Patient Care
Renal anatomy and physiology
Definition of Chronic Kidney Disease
CKD Risk Factors
Gaps in CKD Diagnosis
Slide Number 10
Steps to CKD Patient Care
creatinine
Glomerular filtration rate
Slide Number 14
Slide Number 15
Use These Equations Cautiously if at all in hellip
lab albumin creatinine ratio
The New CKD Categories
Steps to CKD Patient Care
Slide Number 20
Kidney Involvement in Systemic Diseases
Slide Number 22
Slide Number 23
DysmorphicRenal Hematuria
Slide Number 25
If you have albuminuria or hematuria-order the following labs
Prevalence of Abnormalities of Mineral Metabolism PTH in CKD
Managing CKD-MBD complications
CKD-MBD Testing
Anemia Becomes More Common as Kidney Function Declines
Detect and Manage CKD Complications
Complications-metabolic acidosis
Complications-vascular calcification
Hyperkalemia management
Hyperuricemia levels amp CKD
CKD monitoring levels 345
Slide Number 59
When to Refer to a Nephrologist
When to Refer
Steps to CKD Patient Care
Kidney transplantation
Starting Dialysis in the ElderlyhellipOr Not
Ckd management
Case 1
Slide Number 67
Lab results
Slide Number 69
Hypertensive nephropathy with proteinuria
Slide Number 71
Case 2
Slide Number 73
Management of CKD in Diabetes
Case 3
Case 3
Systemic Lupus Erythematosus (SLE)
SLE ndash Lupus Nephritis
Case 5
Case 5
Slide Number 81
Slide Number 82
Case study
Slide Number 84
CXR ndash Hilar Lymphadenopathy
Whats needed next
Slide Number 87
newly dx ckd
Slide Number 89
Bibliography
bibliography
bibliography
bibliography
bibliography
Stage 12
Stage 3
Stage 4
Stage 5
Hb le10 gdL
52
56
11
272
Hb gt10-le12 gdL
216
359
426
483
Hb le12 gdL
267
416
536
755
Stage 12
Stage 3
Stage 4
Stage 5
CKD RISK FACTORS
Modifiablebull Diabetesbull Hypertensionbull History of AKIbull Frequent NSAID use
bull Obesity
bull Hyperuricemia
bull Smoking
bull Sedentary lifestyle
bull Dietary Protein Intake
Non-modifiablebull Family history of kidney disease diabetes or
hypertension
bull Age 60 or older (GFR declines normally with age)
bull RaceUS ethnic minority status
Partial listAKI acute kidney injury (Kidney Disease Improving Global Outcomes (KDIGO) CKD Work Group 2013)
GAPS IN CKD DIAGNOSIS
Szczech Lynda A et al Primary Care Detection of Chronic Kidney Disease in Adults with Type-2 Diabetes The ADD-CKD Study (Awareness Detection and Drug Therapy in Type-2 Diabetes and Chronic Kidney Disease) PLOS One - In press (2014)
0
10
20
30
40
50
60
Not Appropriately Tested Appropriately tested - no diagnosis Appropriately tested - accurate diagnosis
CKD Screening in Primary Care( of patients)
of Patients
Improved Diagnosishellip
Studies demonstrate that clinician behavior changes when CKD diagnosis improves Significant improvements realized in1-3
bull Increased urinary albumin testingbull Increased appropriate use of ACEi or ARBbull Avoidance of NSAIDs prescribing among patients
with low eGFRbull Appropriate nephrology consultation
1 Wei L et al Kidney Int 201384174-1782 Chan M et al Am J Med 20071201063-10703 Fink J et al Am J Kidney Dis 200953681-668
STEPS TO CKD PATIENT CARE
1 CKD definition and risks2 Assess GFR albuminuria (knowing the labs)3 Determine etiology4 Slow progression5 Assess for associated complications6 Discuss dialysistransplantation
CREATININEbull Creatinine is derived from the metabolism of creatine in skeletal
muscle and from dietary meat intake
creatinine secretion by the renal tubules + creatine intake (ie diet)+ creatinine pool size (ie muscle mass) all remain constant
bull GFR is equal to the sum of the filtration rates in all of the functioning nephrons
bull Glomeruli filter 180Lday (125mLmin) of plasma
bull Normal GFR depends on age sex body size and is approximately 130mLmin for men and 120mLmin for womenmdashwith considerable variation
bull CKD-EPI equation (estimated GFR in mLmin173m2) is most accurate
Age Gender RaceSCr
(mgdL) eGFR (mLmin173 m2)
20 M B 13 91
20 M W 13 75
55 M W 13 61
20 F W 13 56
55 F B 13 55
50 F W 13 46
B = black W = all ethnic groups other than blackWith evidence of kidney damage
(Duncan Heathcoat Djurdjev amp Levin 2001)(National Kidney Foundation 2002)
or lt 15 mLmin173m2
(Levey et al 2009)
True GFR could be gt 70 mLmin173m2
The ldquoerdquo in eGFR Stands for ldquoEstimatedrdquohellip
USE THESE EQUATIONS CAUTIOUSLY IF AT ALL IN hellip
bull Patients who haveare
bull Poor nutritionloss of muscle mass
bull Amputation
bull Chronic illness
bull Not African American or Caucasian
bull Changing serum creatinine
bull Obese
bull Very elderly young
(National Kidney Foundation 2014)
LAB ALBUMIN CREATININE RATIO
bull Urinary albumin-to-creatinine ratio (ACR) is calculated by dividing albumin concentration in milligrams by creatinine concentration in grams
bull Creatinine assists in adjusting albumin levels for varying urine concentrations which allows for more accurate results versus albumin alone
bull Spot urine albumin-to-creatinine ratio for quantification of proteinuria
bull New guidelines classify albuminuria as mild moderately or severely increased
bull First morning void preferable
bull 24hr urine test rarely necessary
THE NEW CKD CATEGORIES
STEPS TO CKD PATIENT CARE
1 CKD definition and risks2 Assess GFR albuminuria3 Determine etiology- what is going on here4 Slow progression5 Assess for associated complications6 Discuss dialysistransplantation
(Pal 2012)
KIDNEY INVOLVEMENT IN SYSTEMIC DISEASES
Hypertension
DiabetesAmyloidosis
Sickle cell diseases
Immune complex GN
Illicit drugs ndash cocaine heroin
Cholesterol emboli
HIV
Allergic reactions- drugsinterstitial nephritis
Hemolytic Uremic syndrome
Lupus
Systemic vasculitis
Liver FailureCongestive heart Failure
Image retrieved on 05 October 2010 from httpenwikipediaorgwikiFileGray1129pngThis image is under the public domain and not copyrightable in the US as per Bridgeman Art Library v Corel Corp
(Vasudev amp Vasudev 2012)
New CKD
Obtain ultrasound UA
microscopy albumincr ratio
Ultrasound shows
obstruction
bull Yes Relieve obstruction
bull No Is there albuminuria or glomerular bleeding (eval for glomerulo-nephritis
Fatehi amp Chi-yuan 2016
If red cells have their typical shape and color this indicates extra glomerular hematuria
Examples kidney stone disease UTI cystitis bleeding from collecting duct ureters bladder or urethra
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileReactive_lymphJPGCreative Commons License associated httpcreativecommonsorglicensesby-sa30deeden
(Vasudev amp Vasudev 2012)
DYSMORPHICRENAL HEMATURIA
bull This hematuria is characterized by bull a great variation in the size of the cells and by a high
percentage of dysmorphocytosiscasts (gt20)
bull Hematuria is usually related to glomerular bleeding bull It is typically accompanied by variable levels of albumuniuria
(Vasudev amp Vasudev 2012)
Urinary Cast Formation
Urine Microscopy can be helpful in work up of chronic kidney disease
In GNrsquos the red blood cells leak from the glomerulus into the tubules As they traverse through the tubules they can form cylindrical casts calledRBC casts
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileRedbloodcellsjpgThis image is a work of the National Institutes of Health part of the United States Department of Health and Human Services As a work of the US federal government the image is in the public domain
(Vasudev amp Vasudev 2012)
IF YOU HAVE ALBUMINURIA OR HEMATURIA-ORDER THE FOLLOWING LABS
Tests of autoimmunity Hepatitis serologies gt40 years- paraproteinassessment
ANA Hepatitis B serology (HBsAG)
Serum protein electrophoresis (SPEP)
RFanti-ccp Hepatitis C serology(HCV antibody)
Urine protein electrophoresis (UPEP)
Complement C3 C4
ANCANational Kidney Disease Education Program 2014 NIH
UPTODATE LAB RECOMENDATIONS
bull Lab to order cbc cmp urine albumincr ratio urine microscopy
bull Nephrotic pattern (protein gt35gday) ANA anti DS DNA C3 and C4 antibodies HIV HBV HCV serumurine immunofixation (amyloidosis) free light chain analysis (light chain deposition disease)
bull Nephritic pattern (red cells white cells casts variable protein) C3 C4 ANA dsDNA antineutrophil cytoplasmic antibody (ANCA) titers a streptozyme test HBV and HCV serologies HIV and in some cases blood cultures anti-glomerular basement membrane (GBM) antibodies and cryoglobulins
bull Renal biopsy(Hebert amp Parikh 2014)
EVALUATION OF NEW CKDNO OBSTRUCTION
NO EVIDENCE OF GLOMERULAR BLEEDING
High risk for multmyeloma (gt40
no nsaids no contrast
SPEP UPEP with immunofixation serum free light
chains
Evaluation depends on UA
Sterile pyuria
Eval for interstitial nephritis
Normal urinalysis
High risk for renovascular
disease
Eval for renovascular
disease
Follow serum creatinine-does it
remain stable(Fatehi amp Chi-yuan 2016)
POSSIBLE INVESTIGATIONShellip
Acute interstitial nephritisbull Drugs are the most common cause of AIN
DIABETIC NEPHROPATHY 1 CAUSE OF CKDbull Clinical syndromebull Albuminuria gt30 mg 24 hrsbull Proteinuria gt500 mg24 hrsbull Hypertension developsbull Progressive increase in proteinuriabull Progressive decline in glomerular filtration rate
bull Chronic kidney disease should be attributed to diabetic nephropathies in most patients with diabetes if albuminuria and diabetic retinopathy are both present other causes of CKD should be entertained if diabetic retinopathy is absent (KDIGO 2007)
DIABETIC NEPHROPATHY MORTALITY
bull After 40 yrs of DM
bull 10 alive if proteinuria is present
bull 70 alive if proteinuria is absent
bull Heart Disease is 15 times higher risk in those with proteinuria
bull Proteinuria = death in this population
Dunkler et al 2015
GOALS OF CARE IN CKD GLUCOSE CONTROL
bull Target HbA1c ~70 (lt695 greatest chance of reducing albuminuria)bull Can be extended above 70 with comorbidities or limited life expectancy and
risk of hypoglycemiabull Risk of hypoglycemia increases as kidney function becomes impairedbull Declining kidney function may necessitate changes to diabetes medications and
bull Just having HTN can cause proteinuriabull Usually 1-2 gms of protein a daybull Treat them like a diabetic with ACEI or ARBS and tight blood
pressure controlbull JNC-8 goal lt14090 for ptrsquos with CKDbull National kidney foundation lt14090 if ckd and no proteinuria
lt13080 if proteinuria present
(James Ortiz amp Et Al 2014)
TREATING HYPERTENSIONPROTEINURIA ACEI ORARBbull Riskbenefit should be carefully assessed in the elderly and medically fragilebull Check labs after initiation
bull If less than 30 SCr increase continue and monitorbull If more than 30 SCr increase stop ACEi and evaluate for renal artery stenosis
bull Continue until contraindication arises no absolute eGFR cutoffbull Better proteinuria suppression with low Na diet and diureticsbull Avoid volume depletionbull Avoid ACEi and ARB in combination12
bull Risk of adverse events (impaired kidney function hyperkalemia)
(Kunz Friedrich Wolbers amp Mann 2008)(Mann Schmieder amp McQueen 2008)
bull In adults gt50 yrs statin when eGFR ge 60 mlmin173m2 statin or statinezetimibe combination when eGFR lt 60 mlmin173m2
bull In adults lt 50 yrs statin if history of known CAD MI DM strokebull Aspirin is indicated for secondary but not primary prevention
Kidney Disease Improving Global Outcomes (KDIGO) CKD Work Group Kidney Int Suppls 201331-150
STATINS-RENOPROTECTIVECONTROVERSY
bull HMG-CoA reductase inhibitors (statins) in high doses can cause proteinuria
bull Possibly associated with less inflammation endothelial dysfunction and scarring in the kidney because they also block inflammatory cytokines
bull Use statins for CV disease not to treat proteinuria
(Afzali and Goldsmith 2016)
MEDICINE CAUTION
bull Hold metformin when gfr lt35 mlmin
bull GFR lt50 mlmin should alert to check all doses of meds
bull No bisphosphanates lt35 mlmin
bull No NSAIDScox 2 inhibitors lt60 mlmin
bull Atenolol ndashrenal excretion
bull BACTRIM A lot of AKI
MEDICINE CAUTION
bull Lovenox-use subcut heparinbull Apixibanbull Dabigatranbull Rivaroxibanbull Lithiumbull GABAPENTIN (ckd 4 max 300mg qd ckd 5 max 300mg qod)
STEPS TO CKD PATIENT CARE
1 CKD definition and risks2 Assess GFR albuminuria3 Determine etiology4 Assess for evidence of progression5 Assess for associated complications6 Discuss dialysistransplantation
CKD-CVD-DIABETES LINK CKD IS A DISEASE MULTIPLIER
National kidney foundation 2014
KDIGO 2017
CKD-MINERAL BONE DISORDERS
bull As kidneys fail they
bull Stop activating calcitriol (the active form of Vit D)mdashcausing calcium imbalance
bull Do not remove phosphorus from bloodmdashleading to phosphorus retention
bull The extra phosphorus pulls calcium out of bones causing them to weaken
bull High phosphorus stimulates PTH release
bull These changes (plus others) cause the start of secondary hyperparathyroidism
bull Labs
bull eGFR
bull Calcium
bull Phos
bull Vit D
bull iPTH
(Qunibi amp Henrich 2017)
PREVALENCE OF ABNORMALITIES OF MINERAL METABOLISM PTH IN CKD
bull Progression of disease ndash declining eGFR increasing proteinuria
bull Degree of proteinuria nephrotic syndrome gt 05-10 gd on ACEi or ARB therapy
bull Etiology of CKD not certain
bull Need help with disease management
bull Indications for kidney biopsy
Rosenberg 2016
WHEN TO REFER
STEPS TO CKD PATIENT CARE
1 CKD definition and risks2 Assess GFR albuminuria3 Determine etiology4 Assess for evidence of progression5 Assess for associated complications6 Discuss dialysistransplantation
KIDNEY TRANSPLANTATION
bull Treatment of choice for ESRDbull Improves quality of lifebull Waiting list time varies-3-5 yearsbull 3 year survival rate after transplantation is 83-94bull Increased risk of cancer
STARTING DIALYSIS IN THE ELDERLYhellipOR NOT
bull Among patients gt 75 yrs with stage 5 CKD who chose to NOT start dialysisbull Overall more likely to die over next 1-2 years bull But if they had ischemic heart disease or other significant comorbidity NO
DIFFERENCE in survival
bull Active disease management and supportive care may be appropriate without starting dialysis in the ill elderly
bull Palliative care does not mean ldquono carerdquo
bull Must have end-of-life discussions
(Murtagh et al 2007)
CKD MANAGEMENTbull Diagnose cause and treat underlying conditionbull Stage per guidelinesbull Slow progression of kidney disease (ACE inhibitors)bull Monitor for complicationsmdashvolume overload hyperkalemia metabolic acidosis
hyperphosphatemia anorexia fatigue htn bone diseasebull Labs cmp cbc phos Vit D 25OH iPTH urine microscopy uric acid urine
proteincr ratio-frequency based off heat map Get sono at least oncebull Vaccinate influenza hep B pneumococcalbull Eval ASCVD risk-likely needs statinbull Possible dexa (donrsquot give bisphosphonates if GFRlt35 let specialist manage)bull Refer to nephrology when eGFR is lt30 (sometimes if higher risk-refer earlier)
CASE 1
bull 55 year old man with past medical history of headaches presents to your office for his first time visit to a PCP in over 30 years
bull He has no past history of being admitted to the hospital and he does not take any OTC medsNSAIDsherbal meds He has no history of ETOH abuse smoking or drug use
bull Vitals BP 180100 mmHg pulse 80 R 18
bull Exam No JVD S1S2 regular PMI shifted to the left no gallop no abdominal bruit pulses bilaterally equal and regular no leg edema
bull What would you order
bull EKG cbc cmp ua urine proteincr ratio lipid
LAB RESULTS
bull Labs reveal a creatinine of 22 mgdL eGFR 33 Urine shows no blood or casts Urineprotein ratio shows 1 gm protein24 hrs EKG shows LVH
bull Next step in workupbull Renal ultrasound 1st then SPEP UPEP with immunofixation serum free light chains
bull Additional labs neg Renal ultrasound shows that both kidneys are slightly reduced in size and are mildly echogenic with no mass or hydronephrosis
bull What is your diagnosis
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileMain_complications_of_persistent_high_blood_pressurepngCreative Commons License associated httpcreativecommonsorglicensesby-sa30
bull 3 months Howevermdashwe have evidence of structural abnormalities Could potentially stage at G3b A3 (red on the heat map)
bull Goal blood pressure
bull JNC 8 14090 NKF 13080
bull Additional lab needed for progression monitoring
bull Cbc renal panel phos Vit D iPTH uric acid urine micro (we already have the renal sono and urine proteincr ratio and lipid)
Selective renal angiography (left lower renal artery) after successful percutaneous balloon dilatation of the stenotic lesionFibromuscular dysplasia in an accessory renal artery causing renovascular hypertension
Secondary Hypertension
Images retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileRenal_FMD2jpg and httpcommonswikimediaorgwikiFileRenal_FMDjpgCreative Commons License associated httpcreativecommonsorglicensesby20deeden (both images)
CASE 2bull OS is a 64year old Hispanic female in for DM check She has had DM for 15+ years and is currently
taking metformin 1000mg bid Lisinopril 10mg a day atorvastatin 40mg a day Labs today showed the following
bull Hgba1c 86 cmp eGFR 50 lipid WNL proteincr ratio 650mg These results are similar to her last visit
bull Upon further hx-you find that she had a recent eye exam and has mild nonproliferaive retinopathy She does not have neuropathy or other ss
bull What further workup do you need
bull Renal sonogram urine micro iPTH vit D (25 OH) phos uric acid
bull Dx stage
bull G3a A3
bull What further treatment do you need
bull Improve glycemic control Increase Lisinopril to 20mg with a goal of 40mg Avoid NSAIDs or other nephrotoxic agents make sure meds are renally dosed monitor 3xyear nephro referral
MANAGEMENT OF CKD IN DIABETESeGFR Recommended
All patients
Yearly measurement of creatinine urinary albumin excretion potassium
45-60 Referral to a nephrologist if possibility for nondiabetickidney disease existsConsider dose adjustment of medicationsMonitor eGFR every 6 monthsMonitor electrolytes bicarbonate hemoglobin calcium phosphorus parathyroid hormone at least yearly
Assure vitamin D sufficiencyConsider bone density testingReferral for dietary counselling
American Diabetes Association Standards of Medical Care in Diabetes Microvascular complications and foot care Diabetes Care 2017 40 (Suppl 1) S88-S98
CASE 3
bull 19 year old African American woman presents to your clinic with complaints of fatigue joint pains a new rash on her face oral ulcer
bull On exam BP 15080 P 88 Afebrile 96 O2 sats on RAbull GEN No respiratory distress at restbull HEENT painless oral ulcer flat rash over malar eminences sparing the nasolabial fold pallor +bull Lungs CTAbull CVS S1S2 regularbull Abdomen soft NTbull Ext left elbow joint and bilateral wrist joints are swollen and tender
bull What would you orderbull CBC CMP ua urine microscopy (microalbumin or urine proteincr ratio) ANA esr RF anti-ccp uric acid TSH
CASE 3
bull Working dx fatigue oral ulcer joint pain
bull Basic Labs Na 135 K 55 Bicarb 18 BUN 50 Cr 35 eGFR 22 Ca 90 ANA + titer 1640
bull UA 3+ blood 3+ protein RBC casts +
bull Given these results what is the most likely diagnosis
bull What would you do
SYSTEMIC LUPUS ERYTHEMATOSUS (SLE)
bull SLE multisystemic disease Etiology unknown
bull Production of autoantibodies and immune complexes formation
bull There is renal involvement in the great majority of patients with SLE at some time of the evolution 66-90
SLE ndash LUPUS NEPHRITIS
bull Race SLE is more commonsevere in African americans than Caucasiansbull
bull Gender female-to-male ratio of 91
bull Age Most patients develop lupus nephritis early in their disease course SLE is more common among women in the third decade of life and lupus nephritis occurs in patients aged 20-40 years
bull Kidney Biopsy For staging lupus nephritis (Class 1-5)
CASE 5bull A 80 year old man who has not seen a PCP in many years
presents to your clinic for weakness for the past few months On further questioning he tells you that his bones also have been hurting lately and he has developed leg swelling in the past month or so
bull On exam bull BP 16090 P 88 Afebrilebull GEN Thin built manbull HEENT pallor presentbull Lungs clearbull CVS S1S2 regular no rub or gallopbull Abdomen soft NTbull Ext 2 + edema
CASE 5
bull Differentials
bull CHF MI Cancer arthritis
bull Labs
bull CBC CMP urine microscopy urine proteincr ratio ESR TSH EKG BNP pa and lat CXR
bull LABS Urine dipstick negative for protein or blood
bull Basic chem bull Na 136 (135-145) K 51 (35-55) Chloride 108 (96-106) Bicarb 25
Given this presentation and the labs (low anion gap and elevated calcium anemia kidney failure) what will you think of What will you order next
Serum and urine protein electrophoresis
Intratubular refractile casts with surrounding syncytial giant cell reaction with chronic tubulointerstitial nephritis and fibrosis characteristic of myeloma cast nephropathy
Kidney Biopsy
CASE STUDYbull A 35 year old African American woman was seen in the clinic for
chronic cough and dyspnea on exertion She gave history of vague symptoms of fatigue and weight loss of 20 Ibs over the last six months
bull List some differentialsbull TB sarcoid lupus thyroid problems PEbull What would you orderbull PPD cbc cmp UA TSH ANA pa and lat cxr
bull Her labs were significant for mildly elevated calcium level and a creatinine of 20 mgdL eGFR 37
bull She had 750 mg of proteinuriaday
bull PPD neg ANA neg TSH and other labs WNL
bull Assuming this is present more than 3 monthshelliphellipwhat is her ckd stage
bull G3b A3
bull What do we still need
CT scan of chest
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileAnterior_mediastinal_mass_thymomajpgCreative Commons License associated httpcreativecommonsorglicensesby20deeden
CXR ndash HILAR LYMPHADENOPATHY
WHATS NEEDED NEXT
bull Biopsy of hilar lymphadenopathy or renal biopsy
bull DX sarcoidosis
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileSarcoidosis_signs_and_symptomsjpgThis work is in the public domain in the United States because it is a work of the United States Federal Government under the terms of Title 17 Chapter 1 Section 105 of the US Code
NEWLY DX CKD
bull 1) urinalysis microscopy ultrasound proteincr ratio
bull If obstruction-treat
bull No obstruction
bull Hx critical (consider myeloma if high risk)
bull glomerular bleeding or albumin in urine
bull Yes workup for glomerular causes (ANArf hep B C upep spep ANCA complement C3 C4)
bull No sterile pyruria-consider interstitial nephritis
bull High risk renovascular disease Evaluate renovascular disease
Additional Online Resources for CKD LearningbullNational Kidney Foundation wwwkidneyorgbullUnited States Renal Data Service wwwusrdsorgbullCDCrsquos CKD Surveillance Project
httpnccdcdcgovckdbullNational Kidney Disease Education Program
(NKDEP) httpnkdepnihgov
BIBLIOGRAPHY
bull Afzali B amp Goldsmith D J (2016 June 29) Statins and chronic kidney disease (G C Curhan amp A M Sheridan Eds) Retrieved 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsstatins-and-chronic-kidney-disease
bull American Diabetes Association Standards of Medical Care in Diabetes (2017) Microvascular complications and foot care Diabetes Care 2017 (40) S88-S98
bull American Diabetes Association Standards of Medical Care in Diabetes (2017) Microvascular complications and foot care Diabetes Care 40 (suppl 1) S88-S98
bull Berns J S (2017 Mar 22) Treatment of anemia in nondialysis chronic kidney disease (T A Golper amp A M Sheridan Eds) Retrieved from UpToDate httpswww-uptodate-comproxywichitaeducontentstreatment-of-anemia-in-nondialysis-chronic-kidney-disease
bull Chan M Dall A T Fletcher K E Lu N amp Trivedi H (2007) Outcomes in patients with chronic kidney disease referred late to nephrologists a meta-analysis American Journal of Medicine 120(12) 1063-1070
bull Coresh J Selvin E amp Stevens L A (2007) Prevalence of chronic kidny disease in the United States JAMA 298(17) doi101001jama298172038
bull de Brito-Ashurst I Varagunam M Raftery M amp Yagoob M (2009) Bicarbonate supplementation slows progression of CKD and improves nutritional status Journal of American Society of Nephrology (20) 2075-2084
BIBLIOGRAPHY
bull Duncan L Heathcoat J Djurdjev O amp Levin A (2001) Screening for renal disease using serum creatinine who are we missing Nephrology Dialysis and Transplant 16(5) 1042-1046
bull Dunkler D Gao P Lee S F Heinz G Clase C M Tobe S Oberbauer R (2015 August 7) Risk prediction for early CKD in type 2 diabetes Retrieved from Clinical Journal of the American Society of Nephrology httpcjasnasnjournalsorgcontent1081371fullsid=61422554-a5f1-41ac-b696-dcd3b12bd268
bull Fatehi P amp Chi-yuan H (September 15 2016) Diagnostic approach to the patient with newly identified chronic kidney disease (G C Curhan amp A M Sheridan Eds) Retrieved May 7 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsdiagnostic-approach-to-the-patient-with-newly-identified-chronic-kidney-disease
bull Fink J e (2009) Chronic Kidney Disease as an Under-Recognized Threat to Patient Safety American journal of kidney diseases the official journal of the National Kidney Foundation 53(4) 681-688
bull Gaffo A L amp Saag K G (2008 Nov) Management of hyperuricemia and gout in CKD doihttpdxdoiorg101053jajkd200807035
bull Hebert L A amp Parikh S V (2014 June 18) Differential diagnosis and evaluation of glomerular disease (R J Glassock amp A Q Lam Eds) Retrieved May 7 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsdifferential-diagnosis-and-evaluation-of-glomerular-disease
bull Inker L Perrone R D Sterns R H amp Forman J P (2017 March 7) Assessment of kidney function Retrieved from UpToDate httpswww-uptodate-comproxywichitaeducontentsassessment-of-kidney-functionsource=search_resultampsearch=creatinineampselectedTitle=1~150
BIBLIOGRAPHY
bull James P A Ortiz E amp Et Al (2014) Evidence based guideline for the management of high blood pressure in adults (JNC) JAMA 311(5) 507-520
bull Kidney Disease Improving Global Outcomes (KDIGO) CKD Work Group (2013 January) KDIGO 2012 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease Retrieved from Kidney International Supplement httpwwwkidney-internationalorg
bull Kunz R Friedrich C Wolbers M amp Mann J F (2008) Meta-analysis effect of monotherapy and combination therapy with inhibitors of the renin angiotensin system on proteinuria in renal disease Annals of Internal Medicine 148(1) 30-48
bull Levey A Stevens L A Schmid C H Castro A F Feldman H I Kusek J W Coresh J (2009) A new equation to estimate glomerular filtration rate Annals of Internal Medicine 150(9) 604-612
bull Levin A Bakris G L Molitch M Smulders M M Williams L A amp Andress D L (2007 Jan) Prevalence of abnormal serum vitamin D PTH calcium and phosphorus in patients with chronic kidney disease results of the study to evaluate early kidney disease Kidney International 71(1) 31-38 Retrieved from PubMED
bull Mahajan A Simoni J Sheather S Broglio K Rajab M amp Wesson D (2010) Daily oral sodium bicarbonate preserves glomerular filtration rate by slowing its decline in early hypertensive nephropathy Kidney International (78_ 303-309
bull Mann J Schmieder R E amp McQueen M (2008) Renal outcomes with telmisartan ramipril or both in people at high vascular risk (the ONTARGET study) a multicentre randomised doubleblind ocntrolled trial Lancet 372(9638) 547-533
BIBLIOGRAPHY
bull Matovinović M S (2009) Pathophysiology and classification of kidney disease Retrieved from The Journal of the International Federation of Clinical Chemistry and Laboratory Medicine httpwwwifccorgifccfilesdocs20010902pdf
bull Moe S Drueke T Lameire N amp Eknoyan G (2007 Jan) Chronic kidney disease-mineral-bone disorder a new paradigmdoi101053jackd200610005
bull Murtagh F E Marsh J E Donohoe P Ekbal N J Sheerin N S amp Harris F E (2007 July) Dialysis or not A comparative survival study of patients over 75 years with chronic kidney disease stage 5 Retrieved from Nephrology Dialysis and Transplant 22(7) httpswwwncbinlmnihgovpubmed17412702
bull National Kidney Foundation (2002) KDOQI clinical practice guidelines for chronic kidney disease evaluation classification andstratification American Journal of Kidney Disease S1-S266
bull National Kidney Foundation (2014 November 5) Fact Sheets Retrieved from httpwwwkidneyorgnewsnewsroomfactsheetsFastFacts
bull Pal S (2012 June 2) Trends in chronic kidney disease Retrieved from US Pharmacist (37)6 httpswwwuspharmacistcomarticletrends-in-chronic-kidney-disease
bull Qunibi W amp Henrich W L (2017 Jan 19) Overview of chronic kidney disease-mineral and bone disorder (J Berns amp A M Sheridan Eds) Retrieved from UpToDate httpswww-uptodate-comoverview-of-chronic-kidney-disease-mineral-and-bone-disorder-ckd-mbd
bull Rosenberg M (2016 Feb 24) Overview of the management of chronic kidney disease in adults (G C Curhan amp A M Sheridan Eds) Retrieved from UpToDate UpToDate httpswww-uptodate-comproxywichitaeducontentsoverview-of-the-management-of-chronic-kidney-disease-in-adults
BIBLIOGRAPHY
bull Szczech L Stewart R C Hsu-Lin S DeLosky R J Astor B C Fox C H Vassalotti J A (2014) Primary care detection of chronic kidney disease in adults with type 2 diabetes The ADD-CKD Study (Awareness Detection and Drug Therapy in type 2 diabetes and chronic kidney disease PLOS doihttpsdoiorg101371journalpone0110535
bull USRDS (2016) Annual data report 2016 Epidemiology of kidney disease in the United States Retrieved from United States Renal Data System httpswwwusrdsorgadraspx
bull Vasudev B amp Vasudev M (2012) A model curriculum for residents rotating in nephrology MedEDPORTAL doihttpdoiorg1015766mep_2374-82658288
bull Wei L MacDonald T M Jennings C Sheng X amp Flynn R W (2013) Estimated GFR reporting is associated with decreased nonsteroidal anti-inflammatory drug prescribing and increased renal function Kidney International (84)1 174-178
chronic kidney disease in primary care
CKD as a Public Health Issue
Slide Number 3
Costs of CKD in 2013 dollarsUSRDS report
Steps to CKD Patient Care
Renal anatomy and physiology
Definition of Chronic Kidney Disease
CKD Risk Factors
Gaps in CKD Diagnosis
Slide Number 10
Steps to CKD Patient Care
creatinine
Glomerular filtration rate
Slide Number 14
Slide Number 15
Use These Equations Cautiously if at all in hellip
lab albumin creatinine ratio
The New CKD Categories
Steps to CKD Patient Care
Slide Number 20
Kidney Involvement in Systemic Diseases
Slide Number 22
Slide Number 23
DysmorphicRenal Hematuria
Slide Number 25
If you have albuminuria or hematuria-order the following labs
Prevalence of Abnormalities of Mineral Metabolism PTH in CKD
Managing CKD-MBD complications
CKD-MBD Testing
Anemia Becomes More Common as Kidney Function Declines
Detect and Manage CKD Complications
Complications-metabolic acidosis
Complications-vascular calcification
Hyperkalemia management
Hyperuricemia levels amp CKD
CKD monitoring levels 345
Slide Number 59
When to Refer to a Nephrologist
When to Refer
Steps to CKD Patient Care
Kidney transplantation
Starting Dialysis in the ElderlyhellipOr Not
Ckd management
Case 1
Slide Number 67
Lab results
Slide Number 69
Hypertensive nephropathy with proteinuria
Slide Number 71
Case 2
Slide Number 73
Management of CKD in Diabetes
Case 3
Case 3
Systemic Lupus Erythematosus (SLE)
SLE ndash Lupus Nephritis
Case 5
Case 5
Slide Number 81
Slide Number 82
Case study
Slide Number 84
CXR ndash Hilar Lymphadenopathy
Whats needed next
Slide Number 87
newly dx ckd
Slide Number 89
Bibliography
bibliography
bibliography
bibliography
bibliography
Stage 12
Stage 3
Stage 4
Stage 5
Hb le10 gdL
52
56
11
272
Hb gt10-le12 gdL
216
359
426
483
Hb le12 gdL
267
416
536
755
Stage 12
Stage 3
Stage 4
Stage 5
GAPS IN CKD DIAGNOSIS
Szczech Lynda A et al Primary Care Detection of Chronic Kidney Disease in Adults with Type-2 Diabetes The ADD-CKD Study (Awareness Detection and Drug Therapy in Type-2 Diabetes and Chronic Kidney Disease) PLOS One - In press (2014)
0
10
20
30
40
50
60
Not Appropriately Tested Appropriately tested - no diagnosis Appropriately tested - accurate diagnosis
CKD Screening in Primary Care( of patients)
of Patients
Improved Diagnosishellip
Studies demonstrate that clinician behavior changes when CKD diagnosis improves Significant improvements realized in1-3
bull Increased urinary albumin testingbull Increased appropriate use of ACEi or ARBbull Avoidance of NSAIDs prescribing among patients
with low eGFRbull Appropriate nephrology consultation
1 Wei L et al Kidney Int 201384174-1782 Chan M et al Am J Med 20071201063-10703 Fink J et al Am J Kidney Dis 200953681-668
STEPS TO CKD PATIENT CARE
1 CKD definition and risks2 Assess GFR albuminuria (knowing the labs)3 Determine etiology4 Slow progression5 Assess for associated complications6 Discuss dialysistransplantation
CREATININEbull Creatinine is derived from the metabolism of creatine in skeletal
muscle and from dietary meat intake
creatinine secretion by the renal tubules + creatine intake (ie diet)+ creatinine pool size (ie muscle mass) all remain constant
bull GFR is equal to the sum of the filtration rates in all of the functioning nephrons
bull Glomeruli filter 180Lday (125mLmin) of plasma
bull Normal GFR depends on age sex body size and is approximately 130mLmin for men and 120mLmin for womenmdashwith considerable variation
bull CKD-EPI equation (estimated GFR in mLmin173m2) is most accurate
Age Gender RaceSCr
(mgdL) eGFR (mLmin173 m2)
20 M B 13 91
20 M W 13 75
55 M W 13 61
20 F W 13 56
55 F B 13 55
50 F W 13 46
B = black W = all ethnic groups other than blackWith evidence of kidney damage
(Duncan Heathcoat Djurdjev amp Levin 2001)(National Kidney Foundation 2002)
or lt 15 mLmin173m2
(Levey et al 2009)
True GFR could be gt 70 mLmin173m2
The ldquoerdquo in eGFR Stands for ldquoEstimatedrdquohellip
USE THESE EQUATIONS CAUTIOUSLY IF AT ALL IN hellip
bull Patients who haveare
bull Poor nutritionloss of muscle mass
bull Amputation
bull Chronic illness
bull Not African American or Caucasian
bull Changing serum creatinine
bull Obese
bull Very elderly young
(National Kidney Foundation 2014)
LAB ALBUMIN CREATININE RATIO
bull Urinary albumin-to-creatinine ratio (ACR) is calculated by dividing albumin concentration in milligrams by creatinine concentration in grams
bull Creatinine assists in adjusting albumin levels for varying urine concentrations which allows for more accurate results versus albumin alone
bull Spot urine albumin-to-creatinine ratio for quantification of proteinuria
bull New guidelines classify albuminuria as mild moderately or severely increased
bull First morning void preferable
bull 24hr urine test rarely necessary
THE NEW CKD CATEGORIES
STEPS TO CKD PATIENT CARE
1 CKD definition and risks2 Assess GFR albuminuria3 Determine etiology- what is going on here4 Slow progression5 Assess for associated complications6 Discuss dialysistransplantation
(Pal 2012)
KIDNEY INVOLVEMENT IN SYSTEMIC DISEASES
Hypertension
DiabetesAmyloidosis
Sickle cell diseases
Immune complex GN
Illicit drugs ndash cocaine heroin
Cholesterol emboli
HIV
Allergic reactions- drugsinterstitial nephritis
Hemolytic Uremic syndrome
Lupus
Systemic vasculitis
Liver FailureCongestive heart Failure
Image retrieved on 05 October 2010 from httpenwikipediaorgwikiFileGray1129pngThis image is under the public domain and not copyrightable in the US as per Bridgeman Art Library v Corel Corp
(Vasudev amp Vasudev 2012)
New CKD
Obtain ultrasound UA
microscopy albumincr ratio
Ultrasound shows
obstruction
bull Yes Relieve obstruction
bull No Is there albuminuria or glomerular bleeding (eval for glomerulo-nephritis
Fatehi amp Chi-yuan 2016
If red cells have their typical shape and color this indicates extra glomerular hematuria
Examples kidney stone disease UTI cystitis bleeding from collecting duct ureters bladder or urethra
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileReactive_lymphJPGCreative Commons License associated httpcreativecommonsorglicensesby-sa30deeden
(Vasudev amp Vasudev 2012)
DYSMORPHICRENAL HEMATURIA
bull This hematuria is characterized by bull a great variation in the size of the cells and by a high
percentage of dysmorphocytosiscasts (gt20)
bull Hematuria is usually related to glomerular bleeding bull It is typically accompanied by variable levels of albumuniuria
(Vasudev amp Vasudev 2012)
Urinary Cast Formation
Urine Microscopy can be helpful in work up of chronic kidney disease
In GNrsquos the red blood cells leak from the glomerulus into the tubules As they traverse through the tubules they can form cylindrical casts calledRBC casts
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileRedbloodcellsjpgThis image is a work of the National Institutes of Health part of the United States Department of Health and Human Services As a work of the US federal government the image is in the public domain
(Vasudev amp Vasudev 2012)
IF YOU HAVE ALBUMINURIA OR HEMATURIA-ORDER THE FOLLOWING LABS
Tests of autoimmunity Hepatitis serologies gt40 years- paraproteinassessment
ANA Hepatitis B serology (HBsAG)
Serum protein electrophoresis (SPEP)
RFanti-ccp Hepatitis C serology(HCV antibody)
Urine protein electrophoresis (UPEP)
Complement C3 C4
ANCANational Kidney Disease Education Program 2014 NIH
UPTODATE LAB RECOMENDATIONS
bull Lab to order cbc cmp urine albumincr ratio urine microscopy
bull Nephrotic pattern (protein gt35gday) ANA anti DS DNA C3 and C4 antibodies HIV HBV HCV serumurine immunofixation (amyloidosis) free light chain analysis (light chain deposition disease)
bull Nephritic pattern (red cells white cells casts variable protein) C3 C4 ANA dsDNA antineutrophil cytoplasmic antibody (ANCA) titers a streptozyme test HBV and HCV serologies HIV and in some cases blood cultures anti-glomerular basement membrane (GBM) antibodies and cryoglobulins
bull Renal biopsy(Hebert amp Parikh 2014)
EVALUATION OF NEW CKDNO OBSTRUCTION
NO EVIDENCE OF GLOMERULAR BLEEDING
High risk for multmyeloma (gt40
no nsaids no contrast
SPEP UPEP with immunofixation serum free light
chains
Evaluation depends on UA
Sterile pyuria
Eval for interstitial nephritis
Normal urinalysis
High risk for renovascular
disease
Eval for renovascular
disease
Follow serum creatinine-does it
remain stable(Fatehi amp Chi-yuan 2016)
POSSIBLE INVESTIGATIONShellip
Acute interstitial nephritisbull Drugs are the most common cause of AIN
DIABETIC NEPHROPATHY 1 CAUSE OF CKDbull Clinical syndromebull Albuminuria gt30 mg 24 hrsbull Proteinuria gt500 mg24 hrsbull Hypertension developsbull Progressive increase in proteinuriabull Progressive decline in glomerular filtration rate
bull Chronic kidney disease should be attributed to diabetic nephropathies in most patients with diabetes if albuminuria and diabetic retinopathy are both present other causes of CKD should be entertained if diabetic retinopathy is absent (KDIGO 2007)
DIABETIC NEPHROPATHY MORTALITY
bull After 40 yrs of DM
bull 10 alive if proteinuria is present
bull 70 alive if proteinuria is absent
bull Heart Disease is 15 times higher risk in those with proteinuria
bull Proteinuria = death in this population
Dunkler et al 2015
GOALS OF CARE IN CKD GLUCOSE CONTROL
bull Target HbA1c ~70 (lt695 greatest chance of reducing albuminuria)bull Can be extended above 70 with comorbidities or limited life expectancy and
risk of hypoglycemiabull Risk of hypoglycemia increases as kidney function becomes impairedbull Declining kidney function may necessitate changes to diabetes medications and
bull Just having HTN can cause proteinuriabull Usually 1-2 gms of protein a daybull Treat them like a diabetic with ACEI or ARBS and tight blood
pressure controlbull JNC-8 goal lt14090 for ptrsquos with CKDbull National kidney foundation lt14090 if ckd and no proteinuria
lt13080 if proteinuria present
(James Ortiz amp Et Al 2014)
TREATING HYPERTENSIONPROTEINURIA ACEI ORARBbull Riskbenefit should be carefully assessed in the elderly and medically fragilebull Check labs after initiation
bull If less than 30 SCr increase continue and monitorbull If more than 30 SCr increase stop ACEi and evaluate for renal artery stenosis
bull Continue until contraindication arises no absolute eGFR cutoffbull Better proteinuria suppression with low Na diet and diureticsbull Avoid volume depletionbull Avoid ACEi and ARB in combination12
bull Risk of adverse events (impaired kidney function hyperkalemia)
(Kunz Friedrich Wolbers amp Mann 2008)(Mann Schmieder amp McQueen 2008)
bull In adults gt50 yrs statin when eGFR ge 60 mlmin173m2 statin or statinezetimibe combination when eGFR lt 60 mlmin173m2
bull In adults lt 50 yrs statin if history of known CAD MI DM strokebull Aspirin is indicated for secondary but not primary prevention
Kidney Disease Improving Global Outcomes (KDIGO) CKD Work Group Kidney Int Suppls 201331-150
STATINS-RENOPROTECTIVECONTROVERSY
bull HMG-CoA reductase inhibitors (statins) in high doses can cause proteinuria
bull Possibly associated with less inflammation endothelial dysfunction and scarring in the kidney because they also block inflammatory cytokines
bull Use statins for CV disease not to treat proteinuria
(Afzali and Goldsmith 2016)
MEDICINE CAUTION
bull Hold metformin when gfr lt35 mlmin
bull GFR lt50 mlmin should alert to check all doses of meds
bull No bisphosphanates lt35 mlmin
bull No NSAIDScox 2 inhibitors lt60 mlmin
bull Atenolol ndashrenal excretion
bull BACTRIM A lot of AKI
MEDICINE CAUTION
bull Lovenox-use subcut heparinbull Apixibanbull Dabigatranbull Rivaroxibanbull Lithiumbull GABAPENTIN (ckd 4 max 300mg qd ckd 5 max 300mg qod)
STEPS TO CKD PATIENT CARE
1 CKD definition and risks2 Assess GFR albuminuria3 Determine etiology4 Assess for evidence of progression5 Assess for associated complications6 Discuss dialysistransplantation
CKD-CVD-DIABETES LINK CKD IS A DISEASE MULTIPLIER
National kidney foundation 2014
KDIGO 2017
CKD-MINERAL BONE DISORDERS
bull As kidneys fail they
bull Stop activating calcitriol (the active form of Vit D)mdashcausing calcium imbalance
bull Do not remove phosphorus from bloodmdashleading to phosphorus retention
bull The extra phosphorus pulls calcium out of bones causing them to weaken
bull High phosphorus stimulates PTH release
bull These changes (plus others) cause the start of secondary hyperparathyroidism
bull Labs
bull eGFR
bull Calcium
bull Phos
bull Vit D
bull iPTH
(Qunibi amp Henrich 2017)
PREVALENCE OF ABNORMALITIES OF MINERAL METABOLISM PTH IN CKD
bull Progression of disease ndash declining eGFR increasing proteinuria
bull Degree of proteinuria nephrotic syndrome gt 05-10 gd on ACEi or ARB therapy
bull Etiology of CKD not certain
bull Need help with disease management
bull Indications for kidney biopsy
Rosenberg 2016
WHEN TO REFER
STEPS TO CKD PATIENT CARE
1 CKD definition and risks2 Assess GFR albuminuria3 Determine etiology4 Assess for evidence of progression5 Assess for associated complications6 Discuss dialysistransplantation
KIDNEY TRANSPLANTATION
bull Treatment of choice for ESRDbull Improves quality of lifebull Waiting list time varies-3-5 yearsbull 3 year survival rate after transplantation is 83-94bull Increased risk of cancer
STARTING DIALYSIS IN THE ELDERLYhellipOR NOT
bull Among patients gt 75 yrs with stage 5 CKD who chose to NOT start dialysisbull Overall more likely to die over next 1-2 years bull But if they had ischemic heart disease or other significant comorbidity NO
DIFFERENCE in survival
bull Active disease management and supportive care may be appropriate without starting dialysis in the ill elderly
bull Palliative care does not mean ldquono carerdquo
bull Must have end-of-life discussions
(Murtagh et al 2007)
CKD MANAGEMENTbull Diagnose cause and treat underlying conditionbull Stage per guidelinesbull Slow progression of kidney disease (ACE inhibitors)bull Monitor for complicationsmdashvolume overload hyperkalemia metabolic acidosis
hyperphosphatemia anorexia fatigue htn bone diseasebull Labs cmp cbc phos Vit D 25OH iPTH urine microscopy uric acid urine
proteincr ratio-frequency based off heat map Get sono at least oncebull Vaccinate influenza hep B pneumococcalbull Eval ASCVD risk-likely needs statinbull Possible dexa (donrsquot give bisphosphonates if GFRlt35 let specialist manage)bull Refer to nephrology when eGFR is lt30 (sometimes if higher risk-refer earlier)
CASE 1
bull 55 year old man with past medical history of headaches presents to your office for his first time visit to a PCP in over 30 years
bull He has no past history of being admitted to the hospital and he does not take any OTC medsNSAIDsherbal meds He has no history of ETOH abuse smoking or drug use
bull Vitals BP 180100 mmHg pulse 80 R 18
bull Exam No JVD S1S2 regular PMI shifted to the left no gallop no abdominal bruit pulses bilaterally equal and regular no leg edema
bull What would you order
bull EKG cbc cmp ua urine proteincr ratio lipid
LAB RESULTS
bull Labs reveal a creatinine of 22 mgdL eGFR 33 Urine shows no blood or casts Urineprotein ratio shows 1 gm protein24 hrs EKG shows LVH
bull Next step in workupbull Renal ultrasound 1st then SPEP UPEP with immunofixation serum free light chains
bull Additional labs neg Renal ultrasound shows that both kidneys are slightly reduced in size and are mildly echogenic with no mass or hydronephrosis
bull What is your diagnosis
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileMain_complications_of_persistent_high_blood_pressurepngCreative Commons License associated httpcreativecommonsorglicensesby-sa30
bull 3 months Howevermdashwe have evidence of structural abnormalities Could potentially stage at G3b A3 (red on the heat map)
bull Goal blood pressure
bull JNC 8 14090 NKF 13080
bull Additional lab needed for progression monitoring
bull Cbc renal panel phos Vit D iPTH uric acid urine micro (we already have the renal sono and urine proteincr ratio and lipid)
Selective renal angiography (left lower renal artery) after successful percutaneous balloon dilatation of the stenotic lesionFibromuscular dysplasia in an accessory renal artery causing renovascular hypertension
Secondary Hypertension
Images retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileRenal_FMD2jpg and httpcommonswikimediaorgwikiFileRenal_FMDjpgCreative Commons License associated httpcreativecommonsorglicensesby20deeden (both images)
CASE 2bull OS is a 64year old Hispanic female in for DM check She has had DM for 15+ years and is currently
taking metformin 1000mg bid Lisinopril 10mg a day atorvastatin 40mg a day Labs today showed the following
bull Hgba1c 86 cmp eGFR 50 lipid WNL proteincr ratio 650mg These results are similar to her last visit
bull Upon further hx-you find that she had a recent eye exam and has mild nonproliferaive retinopathy She does not have neuropathy or other ss
bull What further workup do you need
bull Renal sonogram urine micro iPTH vit D (25 OH) phos uric acid
bull Dx stage
bull G3a A3
bull What further treatment do you need
bull Improve glycemic control Increase Lisinopril to 20mg with a goal of 40mg Avoid NSAIDs or other nephrotoxic agents make sure meds are renally dosed monitor 3xyear nephro referral
MANAGEMENT OF CKD IN DIABETESeGFR Recommended
All patients
Yearly measurement of creatinine urinary albumin excretion potassium
45-60 Referral to a nephrologist if possibility for nondiabetickidney disease existsConsider dose adjustment of medicationsMonitor eGFR every 6 monthsMonitor electrolytes bicarbonate hemoglobin calcium phosphorus parathyroid hormone at least yearly
Assure vitamin D sufficiencyConsider bone density testingReferral for dietary counselling
American Diabetes Association Standards of Medical Care in Diabetes Microvascular complications and foot care Diabetes Care 2017 40 (Suppl 1) S88-S98
CASE 3
bull 19 year old African American woman presents to your clinic with complaints of fatigue joint pains a new rash on her face oral ulcer
bull On exam BP 15080 P 88 Afebrile 96 O2 sats on RAbull GEN No respiratory distress at restbull HEENT painless oral ulcer flat rash over malar eminences sparing the nasolabial fold pallor +bull Lungs CTAbull CVS S1S2 regularbull Abdomen soft NTbull Ext left elbow joint and bilateral wrist joints are swollen and tender
bull What would you orderbull CBC CMP ua urine microscopy (microalbumin or urine proteincr ratio) ANA esr RF anti-ccp uric acid TSH
CASE 3
bull Working dx fatigue oral ulcer joint pain
bull Basic Labs Na 135 K 55 Bicarb 18 BUN 50 Cr 35 eGFR 22 Ca 90 ANA + titer 1640
bull UA 3+ blood 3+ protein RBC casts +
bull Given these results what is the most likely diagnosis
bull What would you do
SYSTEMIC LUPUS ERYTHEMATOSUS (SLE)
bull SLE multisystemic disease Etiology unknown
bull Production of autoantibodies and immune complexes formation
bull There is renal involvement in the great majority of patients with SLE at some time of the evolution 66-90
SLE ndash LUPUS NEPHRITIS
bull Race SLE is more commonsevere in African americans than Caucasiansbull
bull Gender female-to-male ratio of 91
bull Age Most patients develop lupus nephritis early in their disease course SLE is more common among women in the third decade of life and lupus nephritis occurs in patients aged 20-40 years
bull Kidney Biopsy For staging lupus nephritis (Class 1-5)
CASE 5bull A 80 year old man who has not seen a PCP in many years
presents to your clinic for weakness for the past few months On further questioning he tells you that his bones also have been hurting lately and he has developed leg swelling in the past month or so
bull On exam bull BP 16090 P 88 Afebrilebull GEN Thin built manbull HEENT pallor presentbull Lungs clearbull CVS S1S2 regular no rub or gallopbull Abdomen soft NTbull Ext 2 + edema
CASE 5
bull Differentials
bull CHF MI Cancer arthritis
bull Labs
bull CBC CMP urine microscopy urine proteincr ratio ESR TSH EKG BNP pa and lat CXR
bull LABS Urine dipstick negative for protein or blood
bull Basic chem bull Na 136 (135-145) K 51 (35-55) Chloride 108 (96-106) Bicarb 25
Given this presentation and the labs (low anion gap and elevated calcium anemia kidney failure) what will you think of What will you order next
Serum and urine protein electrophoresis
Intratubular refractile casts with surrounding syncytial giant cell reaction with chronic tubulointerstitial nephritis and fibrosis characteristic of myeloma cast nephropathy
Kidney Biopsy
CASE STUDYbull A 35 year old African American woman was seen in the clinic for
chronic cough and dyspnea on exertion She gave history of vague symptoms of fatigue and weight loss of 20 Ibs over the last six months
bull List some differentialsbull TB sarcoid lupus thyroid problems PEbull What would you orderbull PPD cbc cmp UA TSH ANA pa and lat cxr
bull Her labs were significant for mildly elevated calcium level and a creatinine of 20 mgdL eGFR 37
bull She had 750 mg of proteinuriaday
bull PPD neg ANA neg TSH and other labs WNL
bull Assuming this is present more than 3 monthshelliphellipwhat is her ckd stage
bull G3b A3
bull What do we still need
CT scan of chest
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileAnterior_mediastinal_mass_thymomajpgCreative Commons License associated httpcreativecommonsorglicensesby20deeden
CXR ndash HILAR LYMPHADENOPATHY
WHATS NEEDED NEXT
bull Biopsy of hilar lymphadenopathy or renal biopsy
bull DX sarcoidosis
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileSarcoidosis_signs_and_symptomsjpgThis work is in the public domain in the United States because it is a work of the United States Federal Government under the terms of Title 17 Chapter 1 Section 105 of the US Code
NEWLY DX CKD
bull 1) urinalysis microscopy ultrasound proteincr ratio
bull If obstruction-treat
bull No obstruction
bull Hx critical (consider myeloma if high risk)
bull glomerular bleeding or albumin in urine
bull Yes workup for glomerular causes (ANArf hep B C upep spep ANCA complement C3 C4)
bull No sterile pyruria-consider interstitial nephritis
bull High risk renovascular disease Evaluate renovascular disease
Additional Online Resources for CKD LearningbullNational Kidney Foundation wwwkidneyorgbullUnited States Renal Data Service wwwusrdsorgbullCDCrsquos CKD Surveillance Project
httpnccdcdcgovckdbullNational Kidney Disease Education Program
(NKDEP) httpnkdepnihgov
BIBLIOGRAPHY
bull Afzali B amp Goldsmith D J (2016 June 29) Statins and chronic kidney disease (G C Curhan amp A M Sheridan Eds) Retrieved 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsstatins-and-chronic-kidney-disease
bull American Diabetes Association Standards of Medical Care in Diabetes (2017) Microvascular complications and foot care Diabetes Care 2017 (40) S88-S98
bull American Diabetes Association Standards of Medical Care in Diabetes (2017) Microvascular complications and foot care Diabetes Care 40 (suppl 1) S88-S98
bull Berns J S (2017 Mar 22) Treatment of anemia in nondialysis chronic kidney disease (T A Golper amp A M Sheridan Eds) Retrieved from UpToDate httpswww-uptodate-comproxywichitaeducontentstreatment-of-anemia-in-nondialysis-chronic-kidney-disease
bull Chan M Dall A T Fletcher K E Lu N amp Trivedi H (2007) Outcomes in patients with chronic kidney disease referred late to nephrologists a meta-analysis American Journal of Medicine 120(12) 1063-1070
bull Coresh J Selvin E amp Stevens L A (2007) Prevalence of chronic kidny disease in the United States JAMA 298(17) doi101001jama298172038
bull de Brito-Ashurst I Varagunam M Raftery M amp Yagoob M (2009) Bicarbonate supplementation slows progression of CKD and improves nutritional status Journal of American Society of Nephrology (20) 2075-2084
BIBLIOGRAPHY
bull Duncan L Heathcoat J Djurdjev O amp Levin A (2001) Screening for renal disease using serum creatinine who are we missing Nephrology Dialysis and Transplant 16(5) 1042-1046
bull Dunkler D Gao P Lee S F Heinz G Clase C M Tobe S Oberbauer R (2015 August 7) Risk prediction for early CKD in type 2 diabetes Retrieved from Clinical Journal of the American Society of Nephrology httpcjasnasnjournalsorgcontent1081371fullsid=61422554-a5f1-41ac-b696-dcd3b12bd268
bull Fatehi P amp Chi-yuan H (September 15 2016) Diagnostic approach to the patient with newly identified chronic kidney disease (G C Curhan amp A M Sheridan Eds) Retrieved May 7 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsdiagnostic-approach-to-the-patient-with-newly-identified-chronic-kidney-disease
bull Fink J e (2009) Chronic Kidney Disease as an Under-Recognized Threat to Patient Safety American journal of kidney diseases the official journal of the National Kidney Foundation 53(4) 681-688
bull Gaffo A L amp Saag K G (2008 Nov) Management of hyperuricemia and gout in CKD doihttpdxdoiorg101053jajkd200807035
bull Hebert L A amp Parikh S V (2014 June 18) Differential diagnosis and evaluation of glomerular disease (R J Glassock amp A Q Lam Eds) Retrieved May 7 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsdifferential-diagnosis-and-evaluation-of-glomerular-disease
bull Inker L Perrone R D Sterns R H amp Forman J P (2017 March 7) Assessment of kidney function Retrieved from UpToDate httpswww-uptodate-comproxywichitaeducontentsassessment-of-kidney-functionsource=search_resultampsearch=creatinineampselectedTitle=1~150
BIBLIOGRAPHY
bull James P A Ortiz E amp Et Al (2014) Evidence based guideline for the management of high blood pressure in adults (JNC) JAMA 311(5) 507-520
bull Kidney Disease Improving Global Outcomes (KDIGO) CKD Work Group (2013 January) KDIGO 2012 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease Retrieved from Kidney International Supplement httpwwwkidney-internationalorg
bull Kunz R Friedrich C Wolbers M amp Mann J F (2008) Meta-analysis effect of monotherapy and combination therapy with inhibitors of the renin angiotensin system on proteinuria in renal disease Annals of Internal Medicine 148(1) 30-48
bull Levey A Stevens L A Schmid C H Castro A F Feldman H I Kusek J W Coresh J (2009) A new equation to estimate glomerular filtration rate Annals of Internal Medicine 150(9) 604-612
bull Levin A Bakris G L Molitch M Smulders M M Williams L A amp Andress D L (2007 Jan) Prevalence of abnormal serum vitamin D PTH calcium and phosphorus in patients with chronic kidney disease results of the study to evaluate early kidney disease Kidney International 71(1) 31-38 Retrieved from PubMED
bull Mahajan A Simoni J Sheather S Broglio K Rajab M amp Wesson D (2010) Daily oral sodium bicarbonate preserves glomerular filtration rate by slowing its decline in early hypertensive nephropathy Kidney International (78_ 303-309
bull Mann J Schmieder R E amp McQueen M (2008) Renal outcomes with telmisartan ramipril or both in people at high vascular risk (the ONTARGET study) a multicentre randomised doubleblind ocntrolled trial Lancet 372(9638) 547-533
BIBLIOGRAPHY
bull Matovinović M S (2009) Pathophysiology and classification of kidney disease Retrieved from The Journal of the International Federation of Clinical Chemistry and Laboratory Medicine httpwwwifccorgifccfilesdocs20010902pdf
bull Moe S Drueke T Lameire N amp Eknoyan G (2007 Jan) Chronic kidney disease-mineral-bone disorder a new paradigmdoi101053jackd200610005
bull Murtagh F E Marsh J E Donohoe P Ekbal N J Sheerin N S amp Harris F E (2007 July) Dialysis or not A comparative survival study of patients over 75 years with chronic kidney disease stage 5 Retrieved from Nephrology Dialysis and Transplant 22(7) httpswwwncbinlmnihgovpubmed17412702
bull National Kidney Foundation (2002) KDOQI clinical practice guidelines for chronic kidney disease evaluation classification andstratification American Journal of Kidney Disease S1-S266
bull National Kidney Foundation (2014 November 5) Fact Sheets Retrieved from httpwwwkidneyorgnewsnewsroomfactsheetsFastFacts
bull Pal S (2012 June 2) Trends in chronic kidney disease Retrieved from US Pharmacist (37)6 httpswwwuspharmacistcomarticletrends-in-chronic-kidney-disease
bull Qunibi W amp Henrich W L (2017 Jan 19) Overview of chronic kidney disease-mineral and bone disorder (J Berns amp A M Sheridan Eds) Retrieved from UpToDate httpswww-uptodate-comoverview-of-chronic-kidney-disease-mineral-and-bone-disorder-ckd-mbd
bull Rosenberg M (2016 Feb 24) Overview of the management of chronic kidney disease in adults (G C Curhan amp A M Sheridan Eds) Retrieved from UpToDate UpToDate httpswww-uptodate-comproxywichitaeducontentsoverview-of-the-management-of-chronic-kidney-disease-in-adults
BIBLIOGRAPHY
bull Szczech L Stewart R C Hsu-Lin S DeLosky R J Astor B C Fox C H Vassalotti J A (2014) Primary care detection of chronic kidney disease in adults with type 2 diabetes The ADD-CKD Study (Awareness Detection and Drug Therapy in type 2 diabetes and chronic kidney disease PLOS doihttpsdoiorg101371journalpone0110535
bull USRDS (2016) Annual data report 2016 Epidemiology of kidney disease in the United States Retrieved from United States Renal Data System httpswwwusrdsorgadraspx
bull Vasudev B amp Vasudev M (2012) A model curriculum for residents rotating in nephrology MedEDPORTAL doihttpdoiorg1015766mep_2374-82658288
bull Wei L MacDonald T M Jennings C Sheng X amp Flynn R W (2013) Estimated GFR reporting is associated with decreased nonsteroidal anti-inflammatory drug prescribing and increased renal function Kidney International (84)1 174-178
chronic kidney disease in primary care
CKD as a Public Health Issue
Slide Number 3
Costs of CKD in 2013 dollarsUSRDS report
Steps to CKD Patient Care
Renal anatomy and physiology
Definition of Chronic Kidney Disease
CKD Risk Factors
Gaps in CKD Diagnosis
Slide Number 10
Steps to CKD Patient Care
creatinine
Glomerular filtration rate
Slide Number 14
Slide Number 15
Use These Equations Cautiously if at all in hellip
lab albumin creatinine ratio
The New CKD Categories
Steps to CKD Patient Care
Slide Number 20
Kidney Involvement in Systemic Diseases
Slide Number 22
Slide Number 23
DysmorphicRenal Hematuria
Slide Number 25
If you have albuminuria or hematuria-order the following labs
bull GFR is equal to the sum of the filtration rates in all of the functioning nephrons
bull Glomeruli filter 180Lday (125mLmin) of plasma
bull Normal GFR depends on age sex body size and is approximately 130mLmin for men and 120mLmin for womenmdashwith considerable variation
bull CKD-EPI equation (estimated GFR in mLmin173m2) is most accurate
Age Gender RaceSCr
(mgdL) eGFR (mLmin173 m2)
20 M B 13 91
20 M W 13 75
55 M W 13 61
20 F W 13 56
55 F B 13 55
50 F W 13 46
B = black W = all ethnic groups other than blackWith evidence of kidney damage
(Duncan Heathcoat Djurdjev amp Levin 2001)(National Kidney Foundation 2002)
or lt 15 mLmin173m2
(Levey et al 2009)
True GFR could be gt 70 mLmin173m2
The ldquoerdquo in eGFR Stands for ldquoEstimatedrdquohellip
USE THESE EQUATIONS CAUTIOUSLY IF AT ALL IN hellip
bull Patients who haveare
bull Poor nutritionloss of muscle mass
bull Amputation
bull Chronic illness
bull Not African American or Caucasian
bull Changing serum creatinine
bull Obese
bull Very elderly young
(National Kidney Foundation 2014)
LAB ALBUMIN CREATININE RATIO
bull Urinary albumin-to-creatinine ratio (ACR) is calculated by dividing albumin concentration in milligrams by creatinine concentration in grams
bull Creatinine assists in adjusting albumin levels for varying urine concentrations which allows for more accurate results versus albumin alone
bull Spot urine albumin-to-creatinine ratio for quantification of proteinuria
bull New guidelines classify albuminuria as mild moderately or severely increased
bull First morning void preferable
bull 24hr urine test rarely necessary
THE NEW CKD CATEGORIES
STEPS TO CKD PATIENT CARE
1 CKD definition and risks2 Assess GFR albuminuria3 Determine etiology- what is going on here4 Slow progression5 Assess for associated complications6 Discuss dialysistransplantation
(Pal 2012)
KIDNEY INVOLVEMENT IN SYSTEMIC DISEASES
Hypertension
DiabetesAmyloidosis
Sickle cell diseases
Immune complex GN
Illicit drugs ndash cocaine heroin
Cholesterol emboli
HIV
Allergic reactions- drugsinterstitial nephritis
Hemolytic Uremic syndrome
Lupus
Systemic vasculitis
Liver FailureCongestive heart Failure
Image retrieved on 05 October 2010 from httpenwikipediaorgwikiFileGray1129pngThis image is under the public domain and not copyrightable in the US as per Bridgeman Art Library v Corel Corp
(Vasudev amp Vasudev 2012)
New CKD
Obtain ultrasound UA
microscopy albumincr ratio
Ultrasound shows
obstruction
bull Yes Relieve obstruction
bull No Is there albuminuria or glomerular bleeding (eval for glomerulo-nephritis
Fatehi amp Chi-yuan 2016
If red cells have their typical shape and color this indicates extra glomerular hematuria
Examples kidney stone disease UTI cystitis bleeding from collecting duct ureters bladder or urethra
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileReactive_lymphJPGCreative Commons License associated httpcreativecommonsorglicensesby-sa30deeden
(Vasudev amp Vasudev 2012)
DYSMORPHICRENAL HEMATURIA
bull This hematuria is characterized by bull a great variation in the size of the cells and by a high
percentage of dysmorphocytosiscasts (gt20)
bull Hematuria is usually related to glomerular bleeding bull It is typically accompanied by variable levels of albumuniuria
(Vasudev amp Vasudev 2012)
Urinary Cast Formation
Urine Microscopy can be helpful in work up of chronic kidney disease
In GNrsquos the red blood cells leak from the glomerulus into the tubules As they traverse through the tubules they can form cylindrical casts calledRBC casts
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileRedbloodcellsjpgThis image is a work of the National Institutes of Health part of the United States Department of Health and Human Services As a work of the US federal government the image is in the public domain
(Vasudev amp Vasudev 2012)
IF YOU HAVE ALBUMINURIA OR HEMATURIA-ORDER THE FOLLOWING LABS
Tests of autoimmunity Hepatitis serologies gt40 years- paraproteinassessment
ANA Hepatitis B serology (HBsAG)
Serum protein electrophoresis (SPEP)
RFanti-ccp Hepatitis C serology(HCV antibody)
Urine protein electrophoresis (UPEP)
Complement C3 C4
ANCANational Kidney Disease Education Program 2014 NIH
UPTODATE LAB RECOMENDATIONS
bull Lab to order cbc cmp urine albumincr ratio urine microscopy
bull Nephrotic pattern (protein gt35gday) ANA anti DS DNA C3 and C4 antibodies HIV HBV HCV serumurine immunofixation (amyloidosis) free light chain analysis (light chain deposition disease)
bull Nephritic pattern (red cells white cells casts variable protein) C3 C4 ANA dsDNA antineutrophil cytoplasmic antibody (ANCA) titers a streptozyme test HBV and HCV serologies HIV and in some cases blood cultures anti-glomerular basement membrane (GBM) antibodies and cryoglobulins
bull Renal biopsy(Hebert amp Parikh 2014)
EVALUATION OF NEW CKDNO OBSTRUCTION
NO EVIDENCE OF GLOMERULAR BLEEDING
High risk for multmyeloma (gt40
no nsaids no contrast
SPEP UPEP with immunofixation serum free light
chains
Evaluation depends on UA
Sterile pyuria
Eval for interstitial nephritis
Normal urinalysis
High risk for renovascular
disease
Eval for renovascular
disease
Follow serum creatinine-does it
remain stable(Fatehi amp Chi-yuan 2016)
POSSIBLE INVESTIGATIONShellip
Acute interstitial nephritisbull Drugs are the most common cause of AIN
DIABETIC NEPHROPATHY 1 CAUSE OF CKDbull Clinical syndromebull Albuminuria gt30 mg 24 hrsbull Proteinuria gt500 mg24 hrsbull Hypertension developsbull Progressive increase in proteinuriabull Progressive decline in glomerular filtration rate
bull Chronic kidney disease should be attributed to diabetic nephropathies in most patients with diabetes if albuminuria and diabetic retinopathy are both present other causes of CKD should be entertained if diabetic retinopathy is absent (KDIGO 2007)
DIABETIC NEPHROPATHY MORTALITY
bull After 40 yrs of DM
bull 10 alive if proteinuria is present
bull 70 alive if proteinuria is absent
bull Heart Disease is 15 times higher risk in those with proteinuria
bull Proteinuria = death in this population
Dunkler et al 2015
GOALS OF CARE IN CKD GLUCOSE CONTROL
bull Target HbA1c ~70 (lt695 greatest chance of reducing albuminuria)bull Can be extended above 70 with comorbidities or limited life expectancy and
risk of hypoglycemiabull Risk of hypoglycemia increases as kidney function becomes impairedbull Declining kidney function may necessitate changes to diabetes medications and
bull Just having HTN can cause proteinuriabull Usually 1-2 gms of protein a daybull Treat them like a diabetic with ACEI or ARBS and tight blood
pressure controlbull JNC-8 goal lt14090 for ptrsquos with CKDbull National kidney foundation lt14090 if ckd and no proteinuria
lt13080 if proteinuria present
(James Ortiz amp Et Al 2014)
TREATING HYPERTENSIONPROTEINURIA ACEI ORARBbull Riskbenefit should be carefully assessed in the elderly and medically fragilebull Check labs after initiation
bull If less than 30 SCr increase continue and monitorbull If more than 30 SCr increase stop ACEi and evaluate for renal artery stenosis
bull Continue until contraindication arises no absolute eGFR cutoffbull Better proteinuria suppression with low Na diet and diureticsbull Avoid volume depletionbull Avoid ACEi and ARB in combination12
bull Risk of adverse events (impaired kidney function hyperkalemia)
(Kunz Friedrich Wolbers amp Mann 2008)(Mann Schmieder amp McQueen 2008)
bull In adults gt50 yrs statin when eGFR ge 60 mlmin173m2 statin or statinezetimibe combination when eGFR lt 60 mlmin173m2
bull In adults lt 50 yrs statin if history of known CAD MI DM strokebull Aspirin is indicated for secondary but not primary prevention
Kidney Disease Improving Global Outcomes (KDIGO) CKD Work Group Kidney Int Suppls 201331-150
STATINS-RENOPROTECTIVECONTROVERSY
bull HMG-CoA reductase inhibitors (statins) in high doses can cause proteinuria
bull Possibly associated with less inflammation endothelial dysfunction and scarring in the kidney because they also block inflammatory cytokines
bull Use statins for CV disease not to treat proteinuria
(Afzali and Goldsmith 2016)
MEDICINE CAUTION
bull Hold metformin when gfr lt35 mlmin
bull GFR lt50 mlmin should alert to check all doses of meds
bull No bisphosphanates lt35 mlmin
bull No NSAIDScox 2 inhibitors lt60 mlmin
bull Atenolol ndashrenal excretion
bull BACTRIM A lot of AKI
MEDICINE CAUTION
bull Lovenox-use subcut heparinbull Apixibanbull Dabigatranbull Rivaroxibanbull Lithiumbull GABAPENTIN (ckd 4 max 300mg qd ckd 5 max 300mg qod)
STEPS TO CKD PATIENT CARE
1 CKD definition and risks2 Assess GFR albuminuria3 Determine etiology4 Assess for evidence of progression5 Assess for associated complications6 Discuss dialysistransplantation
CKD-CVD-DIABETES LINK CKD IS A DISEASE MULTIPLIER
National kidney foundation 2014
KDIGO 2017
CKD-MINERAL BONE DISORDERS
bull As kidneys fail they
bull Stop activating calcitriol (the active form of Vit D)mdashcausing calcium imbalance
bull Do not remove phosphorus from bloodmdashleading to phosphorus retention
bull The extra phosphorus pulls calcium out of bones causing them to weaken
bull High phosphorus stimulates PTH release
bull These changes (plus others) cause the start of secondary hyperparathyroidism
bull Labs
bull eGFR
bull Calcium
bull Phos
bull Vit D
bull iPTH
(Qunibi amp Henrich 2017)
PREVALENCE OF ABNORMALITIES OF MINERAL METABOLISM PTH IN CKD
bull Progression of disease ndash declining eGFR increasing proteinuria
bull Degree of proteinuria nephrotic syndrome gt 05-10 gd on ACEi or ARB therapy
bull Etiology of CKD not certain
bull Need help with disease management
bull Indications for kidney biopsy
Rosenberg 2016
WHEN TO REFER
STEPS TO CKD PATIENT CARE
1 CKD definition and risks2 Assess GFR albuminuria3 Determine etiology4 Assess for evidence of progression5 Assess for associated complications6 Discuss dialysistransplantation
KIDNEY TRANSPLANTATION
bull Treatment of choice for ESRDbull Improves quality of lifebull Waiting list time varies-3-5 yearsbull 3 year survival rate after transplantation is 83-94bull Increased risk of cancer
STARTING DIALYSIS IN THE ELDERLYhellipOR NOT
bull Among patients gt 75 yrs with stage 5 CKD who chose to NOT start dialysisbull Overall more likely to die over next 1-2 years bull But if they had ischemic heart disease or other significant comorbidity NO
DIFFERENCE in survival
bull Active disease management and supportive care may be appropriate without starting dialysis in the ill elderly
bull Palliative care does not mean ldquono carerdquo
bull Must have end-of-life discussions
(Murtagh et al 2007)
CKD MANAGEMENTbull Diagnose cause and treat underlying conditionbull Stage per guidelinesbull Slow progression of kidney disease (ACE inhibitors)bull Monitor for complicationsmdashvolume overload hyperkalemia metabolic acidosis
hyperphosphatemia anorexia fatigue htn bone diseasebull Labs cmp cbc phos Vit D 25OH iPTH urine microscopy uric acid urine
proteincr ratio-frequency based off heat map Get sono at least oncebull Vaccinate influenza hep B pneumococcalbull Eval ASCVD risk-likely needs statinbull Possible dexa (donrsquot give bisphosphonates if GFRlt35 let specialist manage)bull Refer to nephrology when eGFR is lt30 (sometimes if higher risk-refer earlier)
CASE 1
bull 55 year old man with past medical history of headaches presents to your office for his first time visit to a PCP in over 30 years
bull He has no past history of being admitted to the hospital and he does not take any OTC medsNSAIDsherbal meds He has no history of ETOH abuse smoking or drug use
bull Vitals BP 180100 mmHg pulse 80 R 18
bull Exam No JVD S1S2 regular PMI shifted to the left no gallop no abdominal bruit pulses bilaterally equal and regular no leg edema
bull What would you order
bull EKG cbc cmp ua urine proteincr ratio lipid
LAB RESULTS
bull Labs reveal a creatinine of 22 mgdL eGFR 33 Urine shows no blood or casts Urineprotein ratio shows 1 gm protein24 hrs EKG shows LVH
bull Next step in workupbull Renal ultrasound 1st then SPEP UPEP with immunofixation serum free light chains
bull Additional labs neg Renal ultrasound shows that both kidneys are slightly reduced in size and are mildly echogenic with no mass or hydronephrosis
bull What is your diagnosis
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileMain_complications_of_persistent_high_blood_pressurepngCreative Commons License associated httpcreativecommonsorglicensesby-sa30
bull 3 months Howevermdashwe have evidence of structural abnormalities Could potentially stage at G3b A3 (red on the heat map)
bull Goal blood pressure
bull JNC 8 14090 NKF 13080
bull Additional lab needed for progression monitoring
bull Cbc renal panel phos Vit D iPTH uric acid urine micro (we already have the renal sono and urine proteincr ratio and lipid)
Selective renal angiography (left lower renal artery) after successful percutaneous balloon dilatation of the stenotic lesionFibromuscular dysplasia in an accessory renal artery causing renovascular hypertension
Secondary Hypertension
Images retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileRenal_FMD2jpg and httpcommonswikimediaorgwikiFileRenal_FMDjpgCreative Commons License associated httpcreativecommonsorglicensesby20deeden (both images)
CASE 2bull OS is a 64year old Hispanic female in for DM check She has had DM for 15+ years and is currently
taking metformin 1000mg bid Lisinopril 10mg a day atorvastatin 40mg a day Labs today showed the following
bull Hgba1c 86 cmp eGFR 50 lipid WNL proteincr ratio 650mg These results are similar to her last visit
bull Upon further hx-you find that she had a recent eye exam and has mild nonproliferaive retinopathy She does not have neuropathy or other ss
bull What further workup do you need
bull Renal sonogram urine micro iPTH vit D (25 OH) phos uric acid
bull Dx stage
bull G3a A3
bull What further treatment do you need
bull Improve glycemic control Increase Lisinopril to 20mg with a goal of 40mg Avoid NSAIDs or other nephrotoxic agents make sure meds are renally dosed monitor 3xyear nephro referral
MANAGEMENT OF CKD IN DIABETESeGFR Recommended
All patients
Yearly measurement of creatinine urinary albumin excretion potassium
45-60 Referral to a nephrologist if possibility for nondiabetickidney disease existsConsider dose adjustment of medicationsMonitor eGFR every 6 monthsMonitor electrolytes bicarbonate hemoglobin calcium phosphorus parathyroid hormone at least yearly
Assure vitamin D sufficiencyConsider bone density testingReferral for dietary counselling
American Diabetes Association Standards of Medical Care in Diabetes Microvascular complications and foot care Diabetes Care 2017 40 (Suppl 1) S88-S98
CASE 3
bull 19 year old African American woman presents to your clinic with complaints of fatigue joint pains a new rash on her face oral ulcer
bull On exam BP 15080 P 88 Afebrile 96 O2 sats on RAbull GEN No respiratory distress at restbull HEENT painless oral ulcer flat rash over malar eminences sparing the nasolabial fold pallor +bull Lungs CTAbull CVS S1S2 regularbull Abdomen soft NTbull Ext left elbow joint and bilateral wrist joints are swollen and tender
bull What would you orderbull CBC CMP ua urine microscopy (microalbumin or urine proteincr ratio) ANA esr RF anti-ccp uric acid TSH
CASE 3
bull Working dx fatigue oral ulcer joint pain
bull Basic Labs Na 135 K 55 Bicarb 18 BUN 50 Cr 35 eGFR 22 Ca 90 ANA + titer 1640
bull UA 3+ blood 3+ protein RBC casts +
bull Given these results what is the most likely diagnosis
bull What would you do
SYSTEMIC LUPUS ERYTHEMATOSUS (SLE)
bull SLE multisystemic disease Etiology unknown
bull Production of autoantibodies and immune complexes formation
bull There is renal involvement in the great majority of patients with SLE at some time of the evolution 66-90
SLE ndash LUPUS NEPHRITIS
bull Race SLE is more commonsevere in African americans than Caucasiansbull
bull Gender female-to-male ratio of 91
bull Age Most patients develop lupus nephritis early in their disease course SLE is more common among women in the third decade of life and lupus nephritis occurs in patients aged 20-40 years
bull Kidney Biopsy For staging lupus nephritis (Class 1-5)
CASE 5bull A 80 year old man who has not seen a PCP in many years
presents to your clinic for weakness for the past few months On further questioning he tells you that his bones also have been hurting lately and he has developed leg swelling in the past month or so
bull On exam bull BP 16090 P 88 Afebrilebull GEN Thin built manbull HEENT pallor presentbull Lungs clearbull CVS S1S2 regular no rub or gallopbull Abdomen soft NTbull Ext 2 + edema
CASE 5
bull Differentials
bull CHF MI Cancer arthritis
bull Labs
bull CBC CMP urine microscopy urine proteincr ratio ESR TSH EKG BNP pa and lat CXR
bull LABS Urine dipstick negative for protein or blood
bull Basic chem bull Na 136 (135-145) K 51 (35-55) Chloride 108 (96-106) Bicarb 25
Given this presentation and the labs (low anion gap and elevated calcium anemia kidney failure) what will you think of What will you order next
Serum and urine protein electrophoresis
Intratubular refractile casts with surrounding syncytial giant cell reaction with chronic tubulointerstitial nephritis and fibrosis characteristic of myeloma cast nephropathy
Kidney Biopsy
CASE STUDYbull A 35 year old African American woman was seen in the clinic for
chronic cough and dyspnea on exertion She gave history of vague symptoms of fatigue and weight loss of 20 Ibs over the last six months
bull List some differentialsbull TB sarcoid lupus thyroid problems PEbull What would you orderbull PPD cbc cmp UA TSH ANA pa and lat cxr
bull Her labs were significant for mildly elevated calcium level and a creatinine of 20 mgdL eGFR 37
bull She had 750 mg of proteinuriaday
bull PPD neg ANA neg TSH and other labs WNL
bull Assuming this is present more than 3 monthshelliphellipwhat is her ckd stage
bull G3b A3
bull What do we still need
CT scan of chest
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileAnterior_mediastinal_mass_thymomajpgCreative Commons License associated httpcreativecommonsorglicensesby20deeden
CXR ndash HILAR LYMPHADENOPATHY
WHATS NEEDED NEXT
bull Biopsy of hilar lymphadenopathy or renal biopsy
bull DX sarcoidosis
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileSarcoidosis_signs_and_symptomsjpgThis work is in the public domain in the United States because it is a work of the United States Federal Government under the terms of Title 17 Chapter 1 Section 105 of the US Code
NEWLY DX CKD
bull 1) urinalysis microscopy ultrasound proteincr ratio
bull If obstruction-treat
bull No obstruction
bull Hx critical (consider myeloma if high risk)
bull glomerular bleeding or albumin in urine
bull Yes workup for glomerular causes (ANArf hep B C upep spep ANCA complement C3 C4)
bull No sterile pyruria-consider interstitial nephritis
bull High risk renovascular disease Evaluate renovascular disease
Additional Online Resources for CKD LearningbullNational Kidney Foundation wwwkidneyorgbullUnited States Renal Data Service wwwusrdsorgbullCDCrsquos CKD Surveillance Project
httpnccdcdcgovckdbullNational Kidney Disease Education Program
(NKDEP) httpnkdepnihgov
BIBLIOGRAPHY
bull Afzali B amp Goldsmith D J (2016 June 29) Statins and chronic kidney disease (G C Curhan amp A M Sheridan Eds) Retrieved 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsstatins-and-chronic-kidney-disease
bull American Diabetes Association Standards of Medical Care in Diabetes (2017) Microvascular complications and foot care Diabetes Care 2017 (40) S88-S98
bull American Diabetes Association Standards of Medical Care in Diabetes (2017) Microvascular complications and foot care Diabetes Care 40 (suppl 1) S88-S98
bull Berns J S (2017 Mar 22) Treatment of anemia in nondialysis chronic kidney disease (T A Golper amp A M Sheridan Eds) Retrieved from UpToDate httpswww-uptodate-comproxywichitaeducontentstreatment-of-anemia-in-nondialysis-chronic-kidney-disease
bull Chan M Dall A T Fletcher K E Lu N amp Trivedi H (2007) Outcomes in patients with chronic kidney disease referred late to nephrologists a meta-analysis American Journal of Medicine 120(12) 1063-1070
bull Coresh J Selvin E amp Stevens L A (2007) Prevalence of chronic kidny disease in the United States JAMA 298(17) doi101001jama298172038
bull de Brito-Ashurst I Varagunam M Raftery M amp Yagoob M (2009) Bicarbonate supplementation slows progression of CKD and improves nutritional status Journal of American Society of Nephrology (20) 2075-2084
BIBLIOGRAPHY
bull Duncan L Heathcoat J Djurdjev O amp Levin A (2001) Screening for renal disease using serum creatinine who are we missing Nephrology Dialysis and Transplant 16(5) 1042-1046
bull Dunkler D Gao P Lee S F Heinz G Clase C M Tobe S Oberbauer R (2015 August 7) Risk prediction for early CKD in type 2 diabetes Retrieved from Clinical Journal of the American Society of Nephrology httpcjasnasnjournalsorgcontent1081371fullsid=61422554-a5f1-41ac-b696-dcd3b12bd268
bull Fatehi P amp Chi-yuan H (September 15 2016) Diagnostic approach to the patient with newly identified chronic kidney disease (G C Curhan amp A M Sheridan Eds) Retrieved May 7 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsdiagnostic-approach-to-the-patient-with-newly-identified-chronic-kidney-disease
bull Fink J e (2009) Chronic Kidney Disease as an Under-Recognized Threat to Patient Safety American journal of kidney diseases the official journal of the National Kidney Foundation 53(4) 681-688
bull Gaffo A L amp Saag K G (2008 Nov) Management of hyperuricemia and gout in CKD doihttpdxdoiorg101053jajkd200807035
bull Hebert L A amp Parikh S V (2014 June 18) Differential diagnosis and evaluation of glomerular disease (R J Glassock amp A Q Lam Eds) Retrieved May 7 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsdifferential-diagnosis-and-evaluation-of-glomerular-disease
bull Inker L Perrone R D Sterns R H amp Forman J P (2017 March 7) Assessment of kidney function Retrieved from UpToDate httpswww-uptodate-comproxywichitaeducontentsassessment-of-kidney-functionsource=search_resultampsearch=creatinineampselectedTitle=1~150
BIBLIOGRAPHY
bull James P A Ortiz E amp Et Al (2014) Evidence based guideline for the management of high blood pressure in adults (JNC) JAMA 311(5) 507-520
bull Kidney Disease Improving Global Outcomes (KDIGO) CKD Work Group (2013 January) KDIGO 2012 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease Retrieved from Kidney International Supplement httpwwwkidney-internationalorg
bull Kunz R Friedrich C Wolbers M amp Mann J F (2008) Meta-analysis effect of monotherapy and combination therapy with inhibitors of the renin angiotensin system on proteinuria in renal disease Annals of Internal Medicine 148(1) 30-48
bull Levey A Stevens L A Schmid C H Castro A F Feldman H I Kusek J W Coresh J (2009) A new equation to estimate glomerular filtration rate Annals of Internal Medicine 150(9) 604-612
bull Levin A Bakris G L Molitch M Smulders M M Williams L A amp Andress D L (2007 Jan) Prevalence of abnormal serum vitamin D PTH calcium and phosphorus in patients with chronic kidney disease results of the study to evaluate early kidney disease Kidney International 71(1) 31-38 Retrieved from PubMED
bull Mahajan A Simoni J Sheather S Broglio K Rajab M amp Wesson D (2010) Daily oral sodium bicarbonate preserves glomerular filtration rate by slowing its decline in early hypertensive nephropathy Kidney International (78_ 303-309
bull Mann J Schmieder R E amp McQueen M (2008) Renal outcomes with telmisartan ramipril or both in people at high vascular risk (the ONTARGET study) a multicentre randomised doubleblind ocntrolled trial Lancet 372(9638) 547-533
BIBLIOGRAPHY
bull Matovinović M S (2009) Pathophysiology and classification of kidney disease Retrieved from The Journal of the International Federation of Clinical Chemistry and Laboratory Medicine httpwwwifccorgifccfilesdocs20010902pdf
bull Moe S Drueke T Lameire N amp Eknoyan G (2007 Jan) Chronic kidney disease-mineral-bone disorder a new paradigmdoi101053jackd200610005
bull Murtagh F E Marsh J E Donohoe P Ekbal N J Sheerin N S amp Harris F E (2007 July) Dialysis or not A comparative survival study of patients over 75 years with chronic kidney disease stage 5 Retrieved from Nephrology Dialysis and Transplant 22(7) httpswwwncbinlmnihgovpubmed17412702
bull National Kidney Foundation (2002) KDOQI clinical practice guidelines for chronic kidney disease evaluation classification andstratification American Journal of Kidney Disease S1-S266
bull National Kidney Foundation (2014 November 5) Fact Sheets Retrieved from httpwwwkidneyorgnewsnewsroomfactsheetsFastFacts
bull Pal S (2012 June 2) Trends in chronic kidney disease Retrieved from US Pharmacist (37)6 httpswwwuspharmacistcomarticletrends-in-chronic-kidney-disease
bull Qunibi W amp Henrich W L (2017 Jan 19) Overview of chronic kidney disease-mineral and bone disorder (J Berns amp A M Sheridan Eds) Retrieved from UpToDate httpswww-uptodate-comoverview-of-chronic-kidney-disease-mineral-and-bone-disorder-ckd-mbd
bull Rosenberg M (2016 Feb 24) Overview of the management of chronic kidney disease in adults (G C Curhan amp A M Sheridan Eds) Retrieved from UpToDate UpToDate httpswww-uptodate-comproxywichitaeducontentsoverview-of-the-management-of-chronic-kidney-disease-in-adults
BIBLIOGRAPHY
bull Szczech L Stewart R C Hsu-Lin S DeLosky R J Astor B C Fox C H Vassalotti J A (2014) Primary care detection of chronic kidney disease in adults with type 2 diabetes The ADD-CKD Study (Awareness Detection and Drug Therapy in type 2 diabetes and chronic kidney disease PLOS doihttpsdoiorg101371journalpone0110535
bull USRDS (2016) Annual data report 2016 Epidemiology of kidney disease in the United States Retrieved from United States Renal Data System httpswwwusrdsorgadraspx
bull Vasudev B amp Vasudev M (2012) A model curriculum for residents rotating in nephrology MedEDPORTAL doihttpdoiorg1015766mep_2374-82658288
bull Wei L MacDonald T M Jennings C Sheng X amp Flynn R W (2013) Estimated GFR reporting is associated with decreased nonsteroidal anti-inflammatory drug prescribing and increased renal function Kidney International (84)1 174-178
chronic kidney disease in primary care
CKD as a Public Health Issue
Slide Number 3
Costs of CKD in 2013 dollarsUSRDS report
Steps to CKD Patient Care
Renal anatomy and physiology
Definition of Chronic Kidney Disease
CKD Risk Factors
Gaps in CKD Diagnosis
Slide Number 10
Steps to CKD Patient Care
creatinine
Glomerular filtration rate
Slide Number 14
Slide Number 15
Use These Equations Cautiously if at all in hellip
lab albumin creatinine ratio
The New CKD Categories
Steps to CKD Patient Care
Slide Number 20
Kidney Involvement in Systemic Diseases
Slide Number 22
Slide Number 23
DysmorphicRenal Hematuria
Slide Number 25
If you have albuminuria or hematuria-order the following labs
bull GFR is equal to the sum of the filtration rates in all of the functioning nephrons
bull Glomeruli filter 180Lday (125mLmin) of plasma
bull Normal GFR depends on age sex body size and is approximately 130mLmin for men and 120mLmin for womenmdashwith considerable variation
bull CKD-EPI equation (estimated GFR in mLmin173m2) is most accurate
Age Gender RaceSCr
(mgdL) eGFR (mLmin173 m2)
20 M B 13 91
20 M W 13 75
55 M W 13 61
20 F W 13 56
55 F B 13 55
50 F W 13 46
B = black W = all ethnic groups other than blackWith evidence of kidney damage
(Duncan Heathcoat Djurdjev amp Levin 2001)(National Kidney Foundation 2002)
or lt 15 mLmin173m2
(Levey et al 2009)
True GFR could be gt 70 mLmin173m2
The ldquoerdquo in eGFR Stands for ldquoEstimatedrdquohellip
USE THESE EQUATIONS CAUTIOUSLY IF AT ALL IN hellip
bull Patients who haveare
bull Poor nutritionloss of muscle mass
bull Amputation
bull Chronic illness
bull Not African American or Caucasian
bull Changing serum creatinine
bull Obese
bull Very elderly young
(National Kidney Foundation 2014)
LAB ALBUMIN CREATININE RATIO
bull Urinary albumin-to-creatinine ratio (ACR) is calculated by dividing albumin concentration in milligrams by creatinine concentration in grams
bull Creatinine assists in adjusting albumin levels for varying urine concentrations which allows for more accurate results versus albumin alone
bull Spot urine albumin-to-creatinine ratio for quantification of proteinuria
bull New guidelines classify albuminuria as mild moderately or severely increased
bull First morning void preferable
bull 24hr urine test rarely necessary
THE NEW CKD CATEGORIES
STEPS TO CKD PATIENT CARE
1 CKD definition and risks2 Assess GFR albuminuria3 Determine etiology- what is going on here4 Slow progression5 Assess for associated complications6 Discuss dialysistransplantation
(Pal 2012)
KIDNEY INVOLVEMENT IN SYSTEMIC DISEASES
Hypertension
DiabetesAmyloidosis
Sickle cell diseases
Immune complex GN
Illicit drugs ndash cocaine heroin
Cholesterol emboli
HIV
Allergic reactions- drugsinterstitial nephritis
Hemolytic Uremic syndrome
Lupus
Systemic vasculitis
Liver FailureCongestive heart Failure
Image retrieved on 05 October 2010 from httpenwikipediaorgwikiFileGray1129pngThis image is under the public domain and not copyrightable in the US as per Bridgeman Art Library v Corel Corp
(Vasudev amp Vasudev 2012)
New CKD
Obtain ultrasound UA
microscopy albumincr ratio
Ultrasound shows
obstruction
bull Yes Relieve obstruction
bull No Is there albuminuria or glomerular bleeding (eval for glomerulo-nephritis
Fatehi amp Chi-yuan 2016
If red cells have their typical shape and color this indicates extra glomerular hematuria
Examples kidney stone disease UTI cystitis bleeding from collecting duct ureters bladder or urethra
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileReactive_lymphJPGCreative Commons License associated httpcreativecommonsorglicensesby-sa30deeden
(Vasudev amp Vasudev 2012)
DYSMORPHICRENAL HEMATURIA
bull This hematuria is characterized by bull a great variation in the size of the cells and by a high
percentage of dysmorphocytosiscasts (gt20)
bull Hematuria is usually related to glomerular bleeding bull It is typically accompanied by variable levels of albumuniuria
(Vasudev amp Vasudev 2012)
Urinary Cast Formation
Urine Microscopy can be helpful in work up of chronic kidney disease
In GNrsquos the red blood cells leak from the glomerulus into the tubules As they traverse through the tubules they can form cylindrical casts calledRBC casts
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileRedbloodcellsjpgThis image is a work of the National Institutes of Health part of the United States Department of Health and Human Services As a work of the US federal government the image is in the public domain
(Vasudev amp Vasudev 2012)
IF YOU HAVE ALBUMINURIA OR HEMATURIA-ORDER THE FOLLOWING LABS
Tests of autoimmunity Hepatitis serologies gt40 years- paraproteinassessment
ANA Hepatitis B serology (HBsAG)
Serum protein electrophoresis (SPEP)
RFanti-ccp Hepatitis C serology(HCV antibody)
Urine protein electrophoresis (UPEP)
Complement C3 C4
ANCANational Kidney Disease Education Program 2014 NIH
UPTODATE LAB RECOMENDATIONS
bull Lab to order cbc cmp urine albumincr ratio urine microscopy
bull Nephrotic pattern (protein gt35gday) ANA anti DS DNA C3 and C4 antibodies HIV HBV HCV serumurine immunofixation (amyloidosis) free light chain analysis (light chain deposition disease)
bull Nephritic pattern (red cells white cells casts variable protein) C3 C4 ANA dsDNA antineutrophil cytoplasmic antibody (ANCA) titers a streptozyme test HBV and HCV serologies HIV and in some cases blood cultures anti-glomerular basement membrane (GBM) antibodies and cryoglobulins
bull Renal biopsy(Hebert amp Parikh 2014)
EVALUATION OF NEW CKDNO OBSTRUCTION
NO EVIDENCE OF GLOMERULAR BLEEDING
High risk for multmyeloma (gt40
no nsaids no contrast
SPEP UPEP with immunofixation serum free light
chains
Evaluation depends on UA
Sterile pyuria
Eval for interstitial nephritis
Normal urinalysis
High risk for renovascular
disease
Eval for renovascular
disease
Follow serum creatinine-does it
remain stable(Fatehi amp Chi-yuan 2016)
POSSIBLE INVESTIGATIONShellip
Acute interstitial nephritisbull Drugs are the most common cause of AIN
DIABETIC NEPHROPATHY 1 CAUSE OF CKDbull Clinical syndromebull Albuminuria gt30 mg 24 hrsbull Proteinuria gt500 mg24 hrsbull Hypertension developsbull Progressive increase in proteinuriabull Progressive decline in glomerular filtration rate
bull Chronic kidney disease should be attributed to diabetic nephropathies in most patients with diabetes if albuminuria and diabetic retinopathy are both present other causes of CKD should be entertained if diabetic retinopathy is absent (KDIGO 2007)
DIABETIC NEPHROPATHY MORTALITY
bull After 40 yrs of DM
bull 10 alive if proteinuria is present
bull 70 alive if proteinuria is absent
bull Heart Disease is 15 times higher risk in those with proteinuria
bull Proteinuria = death in this population
Dunkler et al 2015
GOALS OF CARE IN CKD GLUCOSE CONTROL
bull Target HbA1c ~70 (lt695 greatest chance of reducing albuminuria)bull Can be extended above 70 with comorbidities or limited life expectancy and
risk of hypoglycemiabull Risk of hypoglycemia increases as kidney function becomes impairedbull Declining kidney function may necessitate changes to diabetes medications and
bull Just having HTN can cause proteinuriabull Usually 1-2 gms of protein a daybull Treat them like a diabetic with ACEI or ARBS and tight blood
pressure controlbull JNC-8 goal lt14090 for ptrsquos with CKDbull National kidney foundation lt14090 if ckd and no proteinuria
lt13080 if proteinuria present
(James Ortiz amp Et Al 2014)
TREATING HYPERTENSIONPROTEINURIA ACEI ORARBbull Riskbenefit should be carefully assessed in the elderly and medically fragilebull Check labs after initiation
bull If less than 30 SCr increase continue and monitorbull If more than 30 SCr increase stop ACEi and evaluate for renal artery stenosis
bull Continue until contraindication arises no absolute eGFR cutoffbull Better proteinuria suppression with low Na diet and diureticsbull Avoid volume depletionbull Avoid ACEi and ARB in combination12
bull Risk of adverse events (impaired kidney function hyperkalemia)
(Kunz Friedrich Wolbers amp Mann 2008)(Mann Schmieder amp McQueen 2008)
bull In adults gt50 yrs statin when eGFR ge 60 mlmin173m2 statin or statinezetimibe combination when eGFR lt 60 mlmin173m2
bull In adults lt 50 yrs statin if history of known CAD MI DM strokebull Aspirin is indicated for secondary but not primary prevention
Kidney Disease Improving Global Outcomes (KDIGO) CKD Work Group Kidney Int Suppls 201331-150
STATINS-RENOPROTECTIVECONTROVERSY
bull HMG-CoA reductase inhibitors (statins) in high doses can cause proteinuria
bull Possibly associated with less inflammation endothelial dysfunction and scarring in the kidney because they also block inflammatory cytokines
bull Use statins for CV disease not to treat proteinuria
(Afzali and Goldsmith 2016)
MEDICINE CAUTION
bull Hold metformin when gfr lt35 mlmin
bull GFR lt50 mlmin should alert to check all doses of meds
bull No bisphosphanates lt35 mlmin
bull No NSAIDScox 2 inhibitors lt60 mlmin
bull Atenolol ndashrenal excretion
bull BACTRIM A lot of AKI
MEDICINE CAUTION
bull Lovenox-use subcut heparinbull Apixibanbull Dabigatranbull Rivaroxibanbull Lithiumbull GABAPENTIN (ckd 4 max 300mg qd ckd 5 max 300mg qod)
STEPS TO CKD PATIENT CARE
1 CKD definition and risks2 Assess GFR albuminuria3 Determine etiology4 Assess for evidence of progression5 Assess for associated complications6 Discuss dialysistransplantation
CKD-CVD-DIABETES LINK CKD IS A DISEASE MULTIPLIER
National kidney foundation 2014
KDIGO 2017
CKD-MINERAL BONE DISORDERS
bull As kidneys fail they
bull Stop activating calcitriol (the active form of Vit D)mdashcausing calcium imbalance
bull Do not remove phosphorus from bloodmdashleading to phosphorus retention
bull The extra phosphorus pulls calcium out of bones causing them to weaken
bull High phosphorus stimulates PTH release
bull These changes (plus others) cause the start of secondary hyperparathyroidism
bull Labs
bull eGFR
bull Calcium
bull Phos
bull Vit D
bull iPTH
(Qunibi amp Henrich 2017)
PREVALENCE OF ABNORMALITIES OF MINERAL METABOLISM PTH IN CKD
bull Progression of disease ndash declining eGFR increasing proteinuria
bull Degree of proteinuria nephrotic syndrome gt 05-10 gd on ACEi or ARB therapy
bull Etiology of CKD not certain
bull Need help with disease management
bull Indications for kidney biopsy
Rosenberg 2016
WHEN TO REFER
STEPS TO CKD PATIENT CARE
1 CKD definition and risks2 Assess GFR albuminuria3 Determine etiology4 Assess for evidence of progression5 Assess for associated complications6 Discuss dialysistransplantation
KIDNEY TRANSPLANTATION
bull Treatment of choice for ESRDbull Improves quality of lifebull Waiting list time varies-3-5 yearsbull 3 year survival rate after transplantation is 83-94bull Increased risk of cancer
STARTING DIALYSIS IN THE ELDERLYhellipOR NOT
bull Among patients gt 75 yrs with stage 5 CKD who chose to NOT start dialysisbull Overall more likely to die over next 1-2 years bull But if they had ischemic heart disease or other significant comorbidity NO
DIFFERENCE in survival
bull Active disease management and supportive care may be appropriate without starting dialysis in the ill elderly
bull Palliative care does not mean ldquono carerdquo
bull Must have end-of-life discussions
(Murtagh et al 2007)
CKD MANAGEMENTbull Diagnose cause and treat underlying conditionbull Stage per guidelinesbull Slow progression of kidney disease (ACE inhibitors)bull Monitor for complicationsmdashvolume overload hyperkalemia metabolic acidosis
hyperphosphatemia anorexia fatigue htn bone diseasebull Labs cmp cbc phos Vit D 25OH iPTH urine microscopy uric acid urine
proteincr ratio-frequency based off heat map Get sono at least oncebull Vaccinate influenza hep B pneumococcalbull Eval ASCVD risk-likely needs statinbull Possible dexa (donrsquot give bisphosphonates if GFRlt35 let specialist manage)bull Refer to nephrology when eGFR is lt30 (sometimes if higher risk-refer earlier)
CASE 1
bull 55 year old man with past medical history of headaches presents to your office for his first time visit to a PCP in over 30 years
bull He has no past history of being admitted to the hospital and he does not take any OTC medsNSAIDsherbal meds He has no history of ETOH abuse smoking or drug use
bull Vitals BP 180100 mmHg pulse 80 R 18
bull Exam No JVD S1S2 regular PMI shifted to the left no gallop no abdominal bruit pulses bilaterally equal and regular no leg edema
bull What would you order
bull EKG cbc cmp ua urine proteincr ratio lipid
LAB RESULTS
bull Labs reveal a creatinine of 22 mgdL eGFR 33 Urine shows no blood or casts Urineprotein ratio shows 1 gm protein24 hrs EKG shows LVH
bull Next step in workupbull Renal ultrasound 1st then SPEP UPEP with immunofixation serum free light chains
bull Additional labs neg Renal ultrasound shows that both kidneys are slightly reduced in size and are mildly echogenic with no mass or hydronephrosis
bull What is your diagnosis
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileMain_complications_of_persistent_high_blood_pressurepngCreative Commons License associated httpcreativecommonsorglicensesby-sa30
bull 3 months Howevermdashwe have evidence of structural abnormalities Could potentially stage at G3b A3 (red on the heat map)
bull Goal blood pressure
bull JNC 8 14090 NKF 13080
bull Additional lab needed for progression monitoring
bull Cbc renal panel phos Vit D iPTH uric acid urine micro (we already have the renal sono and urine proteincr ratio and lipid)
Selective renal angiography (left lower renal artery) after successful percutaneous balloon dilatation of the stenotic lesionFibromuscular dysplasia in an accessory renal artery causing renovascular hypertension
Secondary Hypertension
Images retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileRenal_FMD2jpg and httpcommonswikimediaorgwikiFileRenal_FMDjpgCreative Commons License associated httpcreativecommonsorglicensesby20deeden (both images)
CASE 2bull OS is a 64year old Hispanic female in for DM check She has had DM for 15+ years and is currently
taking metformin 1000mg bid Lisinopril 10mg a day atorvastatin 40mg a day Labs today showed the following
bull Hgba1c 86 cmp eGFR 50 lipid WNL proteincr ratio 650mg These results are similar to her last visit
bull Upon further hx-you find that she had a recent eye exam and has mild nonproliferaive retinopathy She does not have neuropathy or other ss
bull What further workup do you need
bull Renal sonogram urine micro iPTH vit D (25 OH) phos uric acid
bull Dx stage
bull G3a A3
bull What further treatment do you need
bull Improve glycemic control Increase Lisinopril to 20mg with a goal of 40mg Avoid NSAIDs or other nephrotoxic agents make sure meds are renally dosed monitor 3xyear nephro referral
MANAGEMENT OF CKD IN DIABETESeGFR Recommended
All patients
Yearly measurement of creatinine urinary albumin excretion potassium
45-60 Referral to a nephrologist if possibility for nondiabetickidney disease existsConsider dose adjustment of medicationsMonitor eGFR every 6 monthsMonitor electrolytes bicarbonate hemoglobin calcium phosphorus parathyroid hormone at least yearly
Assure vitamin D sufficiencyConsider bone density testingReferral for dietary counselling
American Diabetes Association Standards of Medical Care in Diabetes Microvascular complications and foot care Diabetes Care 2017 40 (Suppl 1) S88-S98
CASE 3
bull 19 year old African American woman presents to your clinic with complaints of fatigue joint pains a new rash on her face oral ulcer
bull On exam BP 15080 P 88 Afebrile 96 O2 sats on RAbull GEN No respiratory distress at restbull HEENT painless oral ulcer flat rash over malar eminences sparing the nasolabial fold pallor +bull Lungs CTAbull CVS S1S2 regularbull Abdomen soft NTbull Ext left elbow joint and bilateral wrist joints are swollen and tender
bull What would you orderbull CBC CMP ua urine microscopy (microalbumin or urine proteincr ratio) ANA esr RF anti-ccp uric acid TSH
CASE 3
bull Working dx fatigue oral ulcer joint pain
bull Basic Labs Na 135 K 55 Bicarb 18 BUN 50 Cr 35 eGFR 22 Ca 90 ANA + titer 1640
bull UA 3+ blood 3+ protein RBC casts +
bull Given these results what is the most likely diagnosis
bull What would you do
SYSTEMIC LUPUS ERYTHEMATOSUS (SLE)
bull SLE multisystemic disease Etiology unknown
bull Production of autoantibodies and immune complexes formation
bull There is renal involvement in the great majority of patients with SLE at some time of the evolution 66-90
SLE ndash LUPUS NEPHRITIS
bull Race SLE is more commonsevere in African americans than Caucasiansbull
bull Gender female-to-male ratio of 91
bull Age Most patients develop lupus nephritis early in their disease course SLE is more common among women in the third decade of life and lupus nephritis occurs in patients aged 20-40 years
bull Kidney Biopsy For staging lupus nephritis (Class 1-5)
CASE 5bull A 80 year old man who has not seen a PCP in many years
presents to your clinic for weakness for the past few months On further questioning he tells you that his bones also have been hurting lately and he has developed leg swelling in the past month or so
bull On exam bull BP 16090 P 88 Afebrilebull GEN Thin built manbull HEENT pallor presentbull Lungs clearbull CVS S1S2 regular no rub or gallopbull Abdomen soft NTbull Ext 2 + edema
CASE 5
bull Differentials
bull CHF MI Cancer arthritis
bull Labs
bull CBC CMP urine microscopy urine proteincr ratio ESR TSH EKG BNP pa and lat CXR
bull LABS Urine dipstick negative for protein or blood
bull Basic chem bull Na 136 (135-145) K 51 (35-55) Chloride 108 (96-106) Bicarb 25
Given this presentation and the labs (low anion gap and elevated calcium anemia kidney failure) what will you think of What will you order next
Serum and urine protein electrophoresis
Intratubular refractile casts with surrounding syncytial giant cell reaction with chronic tubulointerstitial nephritis and fibrosis characteristic of myeloma cast nephropathy
Kidney Biopsy
CASE STUDYbull A 35 year old African American woman was seen in the clinic for
chronic cough and dyspnea on exertion She gave history of vague symptoms of fatigue and weight loss of 20 Ibs over the last six months
bull List some differentialsbull TB sarcoid lupus thyroid problems PEbull What would you orderbull PPD cbc cmp UA TSH ANA pa and lat cxr
bull Her labs were significant for mildly elevated calcium level and a creatinine of 20 mgdL eGFR 37
bull She had 750 mg of proteinuriaday
bull PPD neg ANA neg TSH and other labs WNL
bull Assuming this is present more than 3 monthshelliphellipwhat is her ckd stage
bull G3b A3
bull What do we still need
CT scan of chest
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileAnterior_mediastinal_mass_thymomajpgCreative Commons License associated httpcreativecommonsorglicensesby20deeden
CXR ndash HILAR LYMPHADENOPATHY
WHATS NEEDED NEXT
bull Biopsy of hilar lymphadenopathy or renal biopsy
bull DX sarcoidosis
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileSarcoidosis_signs_and_symptomsjpgThis work is in the public domain in the United States because it is a work of the United States Federal Government under the terms of Title 17 Chapter 1 Section 105 of the US Code
NEWLY DX CKD
bull 1) urinalysis microscopy ultrasound proteincr ratio
bull If obstruction-treat
bull No obstruction
bull Hx critical (consider myeloma if high risk)
bull glomerular bleeding or albumin in urine
bull Yes workup for glomerular causes (ANArf hep B C upep spep ANCA complement C3 C4)
bull No sterile pyruria-consider interstitial nephritis
bull High risk renovascular disease Evaluate renovascular disease
Additional Online Resources for CKD LearningbullNational Kidney Foundation wwwkidneyorgbullUnited States Renal Data Service wwwusrdsorgbullCDCrsquos CKD Surveillance Project
httpnccdcdcgovckdbullNational Kidney Disease Education Program
(NKDEP) httpnkdepnihgov
BIBLIOGRAPHY
bull Afzali B amp Goldsmith D J (2016 June 29) Statins and chronic kidney disease (G C Curhan amp A M Sheridan Eds) Retrieved 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsstatins-and-chronic-kidney-disease
bull American Diabetes Association Standards of Medical Care in Diabetes (2017) Microvascular complications and foot care Diabetes Care 2017 (40) S88-S98
bull American Diabetes Association Standards of Medical Care in Diabetes (2017) Microvascular complications and foot care Diabetes Care 40 (suppl 1) S88-S98
bull Berns J S (2017 Mar 22) Treatment of anemia in nondialysis chronic kidney disease (T A Golper amp A M Sheridan Eds) Retrieved from UpToDate httpswww-uptodate-comproxywichitaeducontentstreatment-of-anemia-in-nondialysis-chronic-kidney-disease
bull Chan M Dall A T Fletcher K E Lu N amp Trivedi H (2007) Outcomes in patients with chronic kidney disease referred late to nephrologists a meta-analysis American Journal of Medicine 120(12) 1063-1070
bull Coresh J Selvin E amp Stevens L A (2007) Prevalence of chronic kidny disease in the United States JAMA 298(17) doi101001jama298172038
bull de Brito-Ashurst I Varagunam M Raftery M amp Yagoob M (2009) Bicarbonate supplementation slows progression of CKD and improves nutritional status Journal of American Society of Nephrology (20) 2075-2084
BIBLIOGRAPHY
bull Duncan L Heathcoat J Djurdjev O amp Levin A (2001) Screening for renal disease using serum creatinine who are we missing Nephrology Dialysis and Transplant 16(5) 1042-1046
bull Dunkler D Gao P Lee S F Heinz G Clase C M Tobe S Oberbauer R (2015 August 7) Risk prediction for early CKD in type 2 diabetes Retrieved from Clinical Journal of the American Society of Nephrology httpcjasnasnjournalsorgcontent1081371fullsid=61422554-a5f1-41ac-b696-dcd3b12bd268
bull Fatehi P amp Chi-yuan H (September 15 2016) Diagnostic approach to the patient with newly identified chronic kidney disease (G C Curhan amp A M Sheridan Eds) Retrieved May 7 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsdiagnostic-approach-to-the-patient-with-newly-identified-chronic-kidney-disease
bull Fink J e (2009) Chronic Kidney Disease as an Under-Recognized Threat to Patient Safety American journal of kidney diseases the official journal of the National Kidney Foundation 53(4) 681-688
bull Gaffo A L amp Saag K G (2008 Nov) Management of hyperuricemia and gout in CKD doihttpdxdoiorg101053jajkd200807035
bull Hebert L A amp Parikh S V (2014 June 18) Differential diagnosis and evaluation of glomerular disease (R J Glassock amp A Q Lam Eds) Retrieved May 7 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsdifferential-diagnosis-and-evaluation-of-glomerular-disease
bull Inker L Perrone R D Sterns R H amp Forman J P (2017 March 7) Assessment of kidney function Retrieved from UpToDate httpswww-uptodate-comproxywichitaeducontentsassessment-of-kidney-functionsource=search_resultampsearch=creatinineampselectedTitle=1~150
BIBLIOGRAPHY
bull James P A Ortiz E amp Et Al (2014) Evidence based guideline for the management of high blood pressure in adults (JNC) JAMA 311(5) 507-520
bull Kidney Disease Improving Global Outcomes (KDIGO) CKD Work Group (2013 January) KDIGO 2012 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease Retrieved from Kidney International Supplement httpwwwkidney-internationalorg
bull Kunz R Friedrich C Wolbers M amp Mann J F (2008) Meta-analysis effect of monotherapy and combination therapy with inhibitors of the renin angiotensin system on proteinuria in renal disease Annals of Internal Medicine 148(1) 30-48
bull Levey A Stevens L A Schmid C H Castro A F Feldman H I Kusek J W Coresh J (2009) A new equation to estimate glomerular filtration rate Annals of Internal Medicine 150(9) 604-612
bull Levin A Bakris G L Molitch M Smulders M M Williams L A amp Andress D L (2007 Jan) Prevalence of abnormal serum vitamin D PTH calcium and phosphorus in patients with chronic kidney disease results of the study to evaluate early kidney disease Kidney International 71(1) 31-38 Retrieved from PubMED
bull Mahajan A Simoni J Sheather S Broglio K Rajab M amp Wesson D (2010) Daily oral sodium bicarbonate preserves glomerular filtration rate by slowing its decline in early hypertensive nephropathy Kidney International (78_ 303-309
bull Mann J Schmieder R E amp McQueen M (2008) Renal outcomes with telmisartan ramipril or both in people at high vascular risk (the ONTARGET study) a multicentre randomised doubleblind ocntrolled trial Lancet 372(9638) 547-533
BIBLIOGRAPHY
bull Matovinović M S (2009) Pathophysiology and classification of kidney disease Retrieved from The Journal of the International Federation of Clinical Chemistry and Laboratory Medicine httpwwwifccorgifccfilesdocs20010902pdf
bull Moe S Drueke T Lameire N amp Eknoyan G (2007 Jan) Chronic kidney disease-mineral-bone disorder a new paradigmdoi101053jackd200610005
bull Murtagh F E Marsh J E Donohoe P Ekbal N J Sheerin N S amp Harris F E (2007 July) Dialysis or not A comparative survival study of patients over 75 years with chronic kidney disease stage 5 Retrieved from Nephrology Dialysis and Transplant 22(7) httpswwwncbinlmnihgovpubmed17412702
bull National Kidney Foundation (2002) KDOQI clinical practice guidelines for chronic kidney disease evaluation classification andstratification American Journal of Kidney Disease S1-S266
bull National Kidney Foundation (2014 November 5) Fact Sheets Retrieved from httpwwwkidneyorgnewsnewsroomfactsheetsFastFacts
bull Pal S (2012 June 2) Trends in chronic kidney disease Retrieved from US Pharmacist (37)6 httpswwwuspharmacistcomarticletrends-in-chronic-kidney-disease
bull Qunibi W amp Henrich W L (2017 Jan 19) Overview of chronic kidney disease-mineral and bone disorder (J Berns amp A M Sheridan Eds) Retrieved from UpToDate httpswww-uptodate-comoverview-of-chronic-kidney-disease-mineral-and-bone-disorder-ckd-mbd
bull Rosenberg M (2016 Feb 24) Overview of the management of chronic kidney disease in adults (G C Curhan amp A M Sheridan Eds) Retrieved from UpToDate UpToDate httpswww-uptodate-comproxywichitaeducontentsoverview-of-the-management-of-chronic-kidney-disease-in-adults
BIBLIOGRAPHY
bull Szczech L Stewart R C Hsu-Lin S DeLosky R J Astor B C Fox C H Vassalotti J A (2014) Primary care detection of chronic kidney disease in adults with type 2 diabetes The ADD-CKD Study (Awareness Detection and Drug Therapy in type 2 diabetes and chronic kidney disease PLOS doihttpsdoiorg101371journalpone0110535
bull USRDS (2016) Annual data report 2016 Epidemiology of kidney disease in the United States Retrieved from United States Renal Data System httpswwwusrdsorgadraspx
bull Vasudev B amp Vasudev M (2012) A model curriculum for residents rotating in nephrology MedEDPORTAL doihttpdoiorg1015766mep_2374-82658288
bull Wei L MacDonald T M Jennings C Sheng X amp Flynn R W (2013) Estimated GFR reporting is associated with decreased nonsteroidal anti-inflammatory drug prescribing and increased renal function Kidney International (84)1 174-178
chronic kidney disease in primary care
CKD as a Public Health Issue
Slide Number 3
Costs of CKD in 2013 dollarsUSRDS report
Steps to CKD Patient Care
Renal anatomy and physiology
Definition of Chronic Kidney Disease
CKD Risk Factors
Gaps in CKD Diagnosis
Slide Number 10
Steps to CKD Patient Care
creatinine
Glomerular filtration rate
Slide Number 14
Slide Number 15
Use These Equations Cautiously if at all in hellip
lab albumin creatinine ratio
The New CKD Categories
Steps to CKD Patient Care
Slide Number 20
Kidney Involvement in Systemic Diseases
Slide Number 22
Slide Number 23
DysmorphicRenal Hematuria
Slide Number 25
If you have albuminuria or hematuria-order the following labs
bull GFR is equal to the sum of the filtration rates in all of the functioning nephrons
bull Glomeruli filter 180Lday (125mLmin) of plasma
bull Normal GFR depends on age sex body size and is approximately 130mLmin for men and 120mLmin for womenmdashwith considerable variation
bull CKD-EPI equation (estimated GFR in mLmin173m2) is most accurate
Age Gender RaceSCr
(mgdL) eGFR (mLmin173 m2)
20 M B 13 91
20 M W 13 75
55 M W 13 61
20 F W 13 56
55 F B 13 55
50 F W 13 46
B = black W = all ethnic groups other than blackWith evidence of kidney damage
(Duncan Heathcoat Djurdjev amp Levin 2001)(National Kidney Foundation 2002)
or lt 15 mLmin173m2
(Levey et al 2009)
True GFR could be gt 70 mLmin173m2
The ldquoerdquo in eGFR Stands for ldquoEstimatedrdquohellip
USE THESE EQUATIONS CAUTIOUSLY IF AT ALL IN hellip
bull Patients who haveare
bull Poor nutritionloss of muscle mass
bull Amputation
bull Chronic illness
bull Not African American or Caucasian
bull Changing serum creatinine
bull Obese
bull Very elderly young
(National Kidney Foundation 2014)
LAB ALBUMIN CREATININE RATIO
bull Urinary albumin-to-creatinine ratio (ACR) is calculated by dividing albumin concentration in milligrams by creatinine concentration in grams
bull Creatinine assists in adjusting albumin levels for varying urine concentrations which allows for more accurate results versus albumin alone
bull Spot urine albumin-to-creatinine ratio for quantification of proteinuria
bull New guidelines classify albuminuria as mild moderately or severely increased
bull First morning void preferable
bull 24hr urine test rarely necessary
THE NEW CKD CATEGORIES
STEPS TO CKD PATIENT CARE
1 CKD definition and risks2 Assess GFR albuminuria3 Determine etiology- what is going on here4 Slow progression5 Assess for associated complications6 Discuss dialysistransplantation
(Pal 2012)
KIDNEY INVOLVEMENT IN SYSTEMIC DISEASES
Hypertension
DiabetesAmyloidosis
Sickle cell diseases
Immune complex GN
Illicit drugs ndash cocaine heroin
Cholesterol emboli
HIV
Allergic reactions- drugsinterstitial nephritis
Hemolytic Uremic syndrome
Lupus
Systemic vasculitis
Liver FailureCongestive heart Failure
Image retrieved on 05 October 2010 from httpenwikipediaorgwikiFileGray1129pngThis image is under the public domain and not copyrightable in the US as per Bridgeman Art Library v Corel Corp
(Vasudev amp Vasudev 2012)
New CKD
Obtain ultrasound UA
microscopy albumincr ratio
Ultrasound shows
obstruction
bull Yes Relieve obstruction
bull No Is there albuminuria or glomerular bleeding (eval for glomerulo-nephritis
Fatehi amp Chi-yuan 2016
If red cells have their typical shape and color this indicates extra glomerular hematuria
Examples kidney stone disease UTI cystitis bleeding from collecting duct ureters bladder or urethra
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileReactive_lymphJPGCreative Commons License associated httpcreativecommonsorglicensesby-sa30deeden
(Vasudev amp Vasudev 2012)
DYSMORPHICRENAL HEMATURIA
bull This hematuria is characterized by bull a great variation in the size of the cells and by a high
percentage of dysmorphocytosiscasts (gt20)
bull Hematuria is usually related to glomerular bleeding bull It is typically accompanied by variable levels of albumuniuria
(Vasudev amp Vasudev 2012)
Urinary Cast Formation
Urine Microscopy can be helpful in work up of chronic kidney disease
In GNrsquos the red blood cells leak from the glomerulus into the tubules As they traverse through the tubules they can form cylindrical casts calledRBC casts
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileRedbloodcellsjpgThis image is a work of the National Institutes of Health part of the United States Department of Health and Human Services As a work of the US federal government the image is in the public domain
(Vasudev amp Vasudev 2012)
IF YOU HAVE ALBUMINURIA OR HEMATURIA-ORDER THE FOLLOWING LABS
Tests of autoimmunity Hepatitis serologies gt40 years- paraproteinassessment
ANA Hepatitis B serology (HBsAG)
Serum protein electrophoresis (SPEP)
RFanti-ccp Hepatitis C serology(HCV antibody)
Urine protein electrophoresis (UPEP)
Complement C3 C4
ANCANational Kidney Disease Education Program 2014 NIH
UPTODATE LAB RECOMENDATIONS
bull Lab to order cbc cmp urine albumincr ratio urine microscopy
bull Nephrotic pattern (protein gt35gday) ANA anti DS DNA C3 and C4 antibodies HIV HBV HCV serumurine immunofixation (amyloidosis) free light chain analysis (light chain deposition disease)
bull Nephritic pattern (red cells white cells casts variable protein) C3 C4 ANA dsDNA antineutrophil cytoplasmic antibody (ANCA) titers a streptozyme test HBV and HCV serologies HIV and in some cases blood cultures anti-glomerular basement membrane (GBM) antibodies and cryoglobulins
bull Renal biopsy(Hebert amp Parikh 2014)
EVALUATION OF NEW CKDNO OBSTRUCTION
NO EVIDENCE OF GLOMERULAR BLEEDING
High risk for multmyeloma (gt40
no nsaids no contrast
SPEP UPEP with immunofixation serum free light
chains
Evaluation depends on UA
Sterile pyuria
Eval for interstitial nephritis
Normal urinalysis
High risk for renovascular
disease
Eval for renovascular
disease
Follow serum creatinine-does it
remain stable(Fatehi amp Chi-yuan 2016)
POSSIBLE INVESTIGATIONShellip
Acute interstitial nephritisbull Drugs are the most common cause of AIN
DIABETIC NEPHROPATHY 1 CAUSE OF CKDbull Clinical syndromebull Albuminuria gt30 mg 24 hrsbull Proteinuria gt500 mg24 hrsbull Hypertension developsbull Progressive increase in proteinuriabull Progressive decline in glomerular filtration rate
bull Chronic kidney disease should be attributed to diabetic nephropathies in most patients with diabetes if albuminuria and diabetic retinopathy are both present other causes of CKD should be entertained if diabetic retinopathy is absent (KDIGO 2007)
DIABETIC NEPHROPATHY MORTALITY
bull After 40 yrs of DM
bull 10 alive if proteinuria is present
bull 70 alive if proteinuria is absent
bull Heart Disease is 15 times higher risk in those with proteinuria
bull Proteinuria = death in this population
Dunkler et al 2015
GOALS OF CARE IN CKD GLUCOSE CONTROL
bull Target HbA1c ~70 (lt695 greatest chance of reducing albuminuria)bull Can be extended above 70 with comorbidities or limited life expectancy and
risk of hypoglycemiabull Risk of hypoglycemia increases as kidney function becomes impairedbull Declining kidney function may necessitate changes to diabetes medications and
bull Just having HTN can cause proteinuriabull Usually 1-2 gms of protein a daybull Treat them like a diabetic with ACEI or ARBS and tight blood
pressure controlbull JNC-8 goal lt14090 for ptrsquos with CKDbull National kidney foundation lt14090 if ckd and no proteinuria
lt13080 if proteinuria present
(James Ortiz amp Et Al 2014)
TREATING HYPERTENSIONPROTEINURIA ACEI ORARBbull Riskbenefit should be carefully assessed in the elderly and medically fragilebull Check labs after initiation
bull If less than 30 SCr increase continue and monitorbull If more than 30 SCr increase stop ACEi and evaluate for renal artery stenosis
bull Continue until contraindication arises no absolute eGFR cutoffbull Better proteinuria suppression with low Na diet and diureticsbull Avoid volume depletionbull Avoid ACEi and ARB in combination12
bull Risk of adverse events (impaired kidney function hyperkalemia)
(Kunz Friedrich Wolbers amp Mann 2008)(Mann Schmieder amp McQueen 2008)
bull In adults gt50 yrs statin when eGFR ge 60 mlmin173m2 statin or statinezetimibe combination when eGFR lt 60 mlmin173m2
bull In adults lt 50 yrs statin if history of known CAD MI DM strokebull Aspirin is indicated for secondary but not primary prevention
Kidney Disease Improving Global Outcomes (KDIGO) CKD Work Group Kidney Int Suppls 201331-150
STATINS-RENOPROTECTIVECONTROVERSY
bull HMG-CoA reductase inhibitors (statins) in high doses can cause proteinuria
bull Possibly associated with less inflammation endothelial dysfunction and scarring in the kidney because they also block inflammatory cytokines
bull Use statins for CV disease not to treat proteinuria
(Afzali and Goldsmith 2016)
MEDICINE CAUTION
bull Hold metformin when gfr lt35 mlmin
bull GFR lt50 mlmin should alert to check all doses of meds
bull No bisphosphanates lt35 mlmin
bull No NSAIDScox 2 inhibitors lt60 mlmin
bull Atenolol ndashrenal excretion
bull BACTRIM A lot of AKI
MEDICINE CAUTION
bull Lovenox-use subcut heparinbull Apixibanbull Dabigatranbull Rivaroxibanbull Lithiumbull GABAPENTIN (ckd 4 max 300mg qd ckd 5 max 300mg qod)
STEPS TO CKD PATIENT CARE
1 CKD definition and risks2 Assess GFR albuminuria3 Determine etiology4 Assess for evidence of progression5 Assess for associated complications6 Discuss dialysistransplantation
CKD-CVD-DIABETES LINK CKD IS A DISEASE MULTIPLIER
National kidney foundation 2014
KDIGO 2017
CKD-MINERAL BONE DISORDERS
bull As kidneys fail they
bull Stop activating calcitriol (the active form of Vit D)mdashcausing calcium imbalance
bull Do not remove phosphorus from bloodmdashleading to phosphorus retention
bull The extra phosphorus pulls calcium out of bones causing them to weaken
bull High phosphorus stimulates PTH release
bull These changes (plus others) cause the start of secondary hyperparathyroidism
bull Labs
bull eGFR
bull Calcium
bull Phos
bull Vit D
bull iPTH
(Qunibi amp Henrich 2017)
PREVALENCE OF ABNORMALITIES OF MINERAL METABOLISM PTH IN CKD
bull Progression of disease ndash declining eGFR increasing proteinuria
bull Degree of proteinuria nephrotic syndrome gt 05-10 gd on ACEi or ARB therapy
bull Etiology of CKD not certain
bull Need help with disease management
bull Indications for kidney biopsy
Rosenberg 2016
WHEN TO REFER
STEPS TO CKD PATIENT CARE
1 CKD definition and risks2 Assess GFR albuminuria3 Determine etiology4 Assess for evidence of progression5 Assess for associated complications6 Discuss dialysistransplantation
KIDNEY TRANSPLANTATION
bull Treatment of choice for ESRDbull Improves quality of lifebull Waiting list time varies-3-5 yearsbull 3 year survival rate after transplantation is 83-94bull Increased risk of cancer
STARTING DIALYSIS IN THE ELDERLYhellipOR NOT
bull Among patients gt 75 yrs with stage 5 CKD who chose to NOT start dialysisbull Overall more likely to die over next 1-2 years bull But if they had ischemic heart disease or other significant comorbidity NO
DIFFERENCE in survival
bull Active disease management and supportive care may be appropriate without starting dialysis in the ill elderly
bull Palliative care does not mean ldquono carerdquo
bull Must have end-of-life discussions
(Murtagh et al 2007)
CKD MANAGEMENTbull Diagnose cause and treat underlying conditionbull Stage per guidelinesbull Slow progression of kidney disease (ACE inhibitors)bull Monitor for complicationsmdashvolume overload hyperkalemia metabolic acidosis
hyperphosphatemia anorexia fatigue htn bone diseasebull Labs cmp cbc phos Vit D 25OH iPTH urine microscopy uric acid urine
proteincr ratio-frequency based off heat map Get sono at least oncebull Vaccinate influenza hep B pneumococcalbull Eval ASCVD risk-likely needs statinbull Possible dexa (donrsquot give bisphosphonates if GFRlt35 let specialist manage)bull Refer to nephrology when eGFR is lt30 (sometimes if higher risk-refer earlier)
CASE 1
bull 55 year old man with past medical history of headaches presents to your office for his first time visit to a PCP in over 30 years
bull He has no past history of being admitted to the hospital and he does not take any OTC medsNSAIDsherbal meds He has no history of ETOH abuse smoking or drug use
bull Vitals BP 180100 mmHg pulse 80 R 18
bull Exam No JVD S1S2 regular PMI shifted to the left no gallop no abdominal bruit pulses bilaterally equal and regular no leg edema
bull What would you order
bull EKG cbc cmp ua urine proteincr ratio lipid
LAB RESULTS
bull Labs reveal a creatinine of 22 mgdL eGFR 33 Urine shows no blood or casts Urineprotein ratio shows 1 gm protein24 hrs EKG shows LVH
bull Next step in workupbull Renal ultrasound 1st then SPEP UPEP with immunofixation serum free light chains
bull Additional labs neg Renal ultrasound shows that both kidneys are slightly reduced in size and are mildly echogenic with no mass or hydronephrosis
bull What is your diagnosis
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileMain_complications_of_persistent_high_blood_pressurepngCreative Commons License associated httpcreativecommonsorglicensesby-sa30
bull 3 months Howevermdashwe have evidence of structural abnormalities Could potentially stage at G3b A3 (red on the heat map)
bull Goal blood pressure
bull JNC 8 14090 NKF 13080
bull Additional lab needed for progression monitoring
bull Cbc renal panel phos Vit D iPTH uric acid urine micro (we already have the renal sono and urine proteincr ratio and lipid)
Selective renal angiography (left lower renal artery) after successful percutaneous balloon dilatation of the stenotic lesionFibromuscular dysplasia in an accessory renal artery causing renovascular hypertension
Secondary Hypertension
Images retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileRenal_FMD2jpg and httpcommonswikimediaorgwikiFileRenal_FMDjpgCreative Commons License associated httpcreativecommonsorglicensesby20deeden (both images)
CASE 2bull OS is a 64year old Hispanic female in for DM check She has had DM for 15+ years and is currently
taking metformin 1000mg bid Lisinopril 10mg a day atorvastatin 40mg a day Labs today showed the following
bull Hgba1c 86 cmp eGFR 50 lipid WNL proteincr ratio 650mg These results are similar to her last visit
bull Upon further hx-you find that she had a recent eye exam and has mild nonproliferaive retinopathy She does not have neuropathy or other ss
bull What further workup do you need
bull Renal sonogram urine micro iPTH vit D (25 OH) phos uric acid
bull Dx stage
bull G3a A3
bull What further treatment do you need
bull Improve glycemic control Increase Lisinopril to 20mg with a goal of 40mg Avoid NSAIDs or other nephrotoxic agents make sure meds are renally dosed monitor 3xyear nephro referral
MANAGEMENT OF CKD IN DIABETESeGFR Recommended
All patients
Yearly measurement of creatinine urinary albumin excretion potassium
45-60 Referral to a nephrologist if possibility for nondiabetickidney disease existsConsider dose adjustment of medicationsMonitor eGFR every 6 monthsMonitor electrolytes bicarbonate hemoglobin calcium phosphorus parathyroid hormone at least yearly
Assure vitamin D sufficiencyConsider bone density testingReferral for dietary counselling
American Diabetes Association Standards of Medical Care in Diabetes Microvascular complications and foot care Diabetes Care 2017 40 (Suppl 1) S88-S98
CASE 3
bull 19 year old African American woman presents to your clinic with complaints of fatigue joint pains a new rash on her face oral ulcer
bull On exam BP 15080 P 88 Afebrile 96 O2 sats on RAbull GEN No respiratory distress at restbull HEENT painless oral ulcer flat rash over malar eminences sparing the nasolabial fold pallor +bull Lungs CTAbull CVS S1S2 regularbull Abdomen soft NTbull Ext left elbow joint and bilateral wrist joints are swollen and tender
bull What would you orderbull CBC CMP ua urine microscopy (microalbumin or urine proteincr ratio) ANA esr RF anti-ccp uric acid TSH
CASE 3
bull Working dx fatigue oral ulcer joint pain
bull Basic Labs Na 135 K 55 Bicarb 18 BUN 50 Cr 35 eGFR 22 Ca 90 ANA + titer 1640
bull UA 3+ blood 3+ protein RBC casts +
bull Given these results what is the most likely diagnosis
bull What would you do
SYSTEMIC LUPUS ERYTHEMATOSUS (SLE)
bull SLE multisystemic disease Etiology unknown
bull Production of autoantibodies and immune complexes formation
bull There is renal involvement in the great majority of patients with SLE at some time of the evolution 66-90
SLE ndash LUPUS NEPHRITIS
bull Race SLE is more commonsevere in African americans than Caucasiansbull
bull Gender female-to-male ratio of 91
bull Age Most patients develop lupus nephritis early in their disease course SLE is more common among women in the third decade of life and lupus nephritis occurs in patients aged 20-40 years
bull Kidney Biopsy For staging lupus nephritis (Class 1-5)
CASE 5bull A 80 year old man who has not seen a PCP in many years
presents to your clinic for weakness for the past few months On further questioning he tells you that his bones also have been hurting lately and he has developed leg swelling in the past month or so
bull On exam bull BP 16090 P 88 Afebrilebull GEN Thin built manbull HEENT pallor presentbull Lungs clearbull CVS S1S2 regular no rub or gallopbull Abdomen soft NTbull Ext 2 + edema
CASE 5
bull Differentials
bull CHF MI Cancer arthritis
bull Labs
bull CBC CMP urine microscopy urine proteincr ratio ESR TSH EKG BNP pa and lat CXR
bull LABS Urine dipstick negative for protein or blood
bull Basic chem bull Na 136 (135-145) K 51 (35-55) Chloride 108 (96-106) Bicarb 25
Given this presentation and the labs (low anion gap and elevated calcium anemia kidney failure) what will you think of What will you order next
Serum and urine protein electrophoresis
Intratubular refractile casts with surrounding syncytial giant cell reaction with chronic tubulointerstitial nephritis and fibrosis characteristic of myeloma cast nephropathy
Kidney Biopsy
CASE STUDYbull A 35 year old African American woman was seen in the clinic for
chronic cough and dyspnea on exertion She gave history of vague symptoms of fatigue and weight loss of 20 Ibs over the last six months
bull List some differentialsbull TB sarcoid lupus thyroid problems PEbull What would you orderbull PPD cbc cmp UA TSH ANA pa and lat cxr
bull Her labs were significant for mildly elevated calcium level and a creatinine of 20 mgdL eGFR 37
bull She had 750 mg of proteinuriaday
bull PPD neg ANA neg TSH and other labs WNL
bull Assuming this is present more than 3 monthshelliphellipwhat is her ckd stage
bull G3b A3
bull What do we still need
CT scan of chest
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileAnterior_mediastinal_mass_thymomajpgCreative Commons License associated httpcreativecommonsorglicensesby20deeden
CXR ndash HILAR LYMPHADENOPATHY
WHATS NEEDED NEXT
bull Biopsy of hilar lymphadenopathy or renal biopsy
bull DX sarcoidosis
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileSarcoidosis_signs_and_symptomsjpgThis work is in the public domain in the United States because it is a work of the United States Federal Government under the terms of Title 17 Chapter 1 Section 105 of the US Code
NEWLY DX CKD
bull 1) urinalysis microscopy ultrasound proteincr ratio
bull If obstruction-treat
bull No obstruction
bull Hx critical (consider myeloma if high risk)
bull glomerular bleeding or albumin in urine
bull Yes workup for glomerular causes (ANArf hep B C upep spep ANCA complement C3 C4)
bull No sterile pyruria-consider interstitial nephritis
bull High risk renovascular disease Evaluate renovascular disease
Additional Online Resources for CKD LearningbullNational Kidney Foundation wwwkidneyorgbullUnited States Renal Data Service wwwusrdsorgbullCDCrsquos CKD Surveillance Project
httpnccdcdcgovckdbullNational Kidney Disease Education Program
(NKDEP) httpnkdepnihgov
BIBLIOGRAPHY
bull Afzali B amp Goldsmith D J (2016 June 29) Statins and chronic kidney disease (G C Curhan amp A M Sheridan Eds) Retrieved 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsstatins-and-chronic-kidney-disease
bull American Diabetes Association Standards of Medical Care in Diabetes (2017) Microvascular complications and foot care Diabetes Care 2017 (40) S88-S98
bull American Diabetes Association Standards of Medical Care in Diabetes (2017) Microvascular complications and foot care Diabetes Care 40 (suppl 1) S88-S98
bull Berns J S (2017 Mar 22) Treatment of anemia in nondialysis chronic kidney disease (T A Golper amp A M Sheridan Eds) Retrieved from UpToDate httpswww-uptodate-comproxywichitaeducontentstreatment-of-anemia-in-nondialysis-chronic-kidney-disease
bull Chan M Dall A T Fletcher K E Lu N amp Trivedi H (2007) Outcomes in patients with chronic kidney disease referred late to nephrologists a meta-analysis American Journal of Medicine 120(12) 1063-1070
bull Coresh J Selvin E amp Stevens L A (2007) Prevalence of chronic kidny disease in the United States JAMA 298(17) doi101001jama298172038
bull de Brito-Ashurst I Varagunam M Raftery M amp Yagoob M (2009) Bicarbonate supplementation slows progression of CKD and improves nutritional status Journal of American Society of Nephrology (20) 2075-2084
BIBLIOGRAPHY
bull Duncan L Heathcoat J Djurdjev O amp Levin A (2001) Screening for renal disease using serum creatinine who are we missing Nephrology Dialysis and Transplant 16(5) 1042-1046
bull Dunkler D Gao P Lee S F Heinz G Clase C M Tobe S Oberbauer R (2015 August 7) Risk prediction for early CKD in type 2 diabetes Retrieved from Clinical Journal of the American Society of Nephrology httpcjasnasnjournalsorgcontent1081371fullsid=61422554-a5f1-41ac-b696-dcd3b12bd268
bull Fatehi P amp Chi-yuan H (September 15 2016) Diagnostic approach to the patient with newly identified chronic kidney disease (G C Curhan amp A M Sheridan Eds) Retrieved May 7 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsdiagnostic-approach-to-the-patient-with-newly-identified-chronic-kidney-disease
bull Fink J e (2009) Chronic Kidney Disease as an Under-Recognized Threat to Patient Safety American journal of kidney diseases the official journal of the National Kidney Foundation 53(4) 681-688
bull Gaffo A L amp Saag K G (2008 Nov) Management of hyperuricemia and gout in CKD doihttpdxdoiorg101053jajkd200807035
bull Hebert L A amp Parikh S V (2014 June 18) Differential diagnosis and evaluation of glomerular disease (R J Glassock amp A Q Lam Eds) Retrieved May 7 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsdifferential-diagnosis-and-evaluation-of-glomerular-disease
bull Inker L Perrone R D Sterns R H amp Forman J P (2017 March 7) Assessment of kidney function Retrieved from UpToDate httpswww-uptodate-comproxywichitaeducontentsassessment-of-kidney-functionsource=search_resultampsearch=creatinineampselectedTitle=1~150
BIBLIOGRAPHY
bull James P A Ortiz E amp Et Al (2014) Evidence based guideline for the management of high blood pressure in adults (JNC) JAMA 311(5) 507-520
bull Kidney Disease Improving Global Outcomes (KDIGO) CKD Work Group (2013 January) KDIGO 2012 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease Retrieved from Kidney International Supplement httpwwwkidney-internationalorg
bull Kunz R Friedrich C Wolbers M amp Mann J F (2008) Meta-analysis effect of monotherapy and combination therapy with inhibitors of the renin angiotensin system on proteinuria in renal disease Annals of Internal Medicine 148(1) 30-48
bull Levey A Stevens L A Schmid C H Castro A F Feldman H I Kusek J W Coresh J (2009) A new equation to estimate glomerular filtration rate Annals of Internal Medicine 150(9) 604-612
bull Levin A Bakris G L Molitch M Smulders M M Williams L A amp Andress D L (2007 Jan) Prevalence of abnormal serum vitamin D PTH calcium and phosphorus in patients with chronic kidney disease results of the study to evaluate early kidney disease Kidney International 71(1) 31-38 Retrieved from PubMED
bull Mahajan A Simoni J Sheather S Broglio K Rajab M amp Wesson D (2010) Daily oral sodium bicarbonate preserves glomerular filtration rate by slowing its decline in early hypertensive nephropathy Kidney International (78_ 303-309
bull Mann J Schmieder R E amp McQueen M (2008) Renal outcomes with telmisartan ramipril or both in people at high vascular risk (the ONTARGET study) a multicentre randomised doubleblind ocntrolled trial Lancet 372(9638) 547-533
BIBLIOGRAPHY
bull Matovinović M S (2009) Pathophysiology and classification of kidney disease Retrieved from The Journal of the International Federation of Clinical Chemistry and Laboratory Medicine httpwwwifccorgifccfilesdocs20010902pdf
bull Moe S Drueke T Lameire N amp Eknoyan G (2007 Jan) Chronic kidney disease-mineral-bone disorder a new paradigmdoi101053jackd200610005
bull Murtagh F E Marsh J E Donohoe P Ekbal N J Sheerin N S amp Harris F E (2007 July) Dialysis or not A comparative survival study of patients over 75 years with chronic kidney disease stage 5 Retrieved from Nephrology Dialysis and Transplant 22(7) httpswwwncbinlmnihgovpubmed17412702
bull National Kidney Foundation (2002) KDOQI clinical practice guidelines for chronic kidney disease evaluation classification andstratification American Journal of Kidney Disease S1-S266
bull National Kidney Foundation (2014 November 5) Fact Sheets Retrieved from httpwwwkidneyorgnewsnewsroomfactsheetsFastFacts
bull Pal S (2012 June 2) Trends in chronic kidney disease Retrieved from US Pharmacist (37)6 httpswwwuspharmacistcomarticletrends-in-chronic-kidney-disease
bull Qunibi W amp Henrich W L (2017 Jan 19) Overview of chronic kidney disease-mineral and bone disorder (J Berns amp A M Sheridan Eds) Retrieved from UpToDate httpswww-uptodate-comoverview-of-chronic-kidney-disease-mineral-and-bone-disorder-ckd-mbd
bull Rosenberg M (2016 Feb 24) Overview of the management of chronic kidney disease in adults (G C Curhan amp A M Sheridan Eds) Retrieved from UpToDate UpToDate httpswww-uptodate-comproxywichitaeducontentsoverview-of-the-management-of-chronic-kidney-disease-in-adults
BIBLIOGRAPHY
bull Szczech L Stewart R C Hsu-Lin S DeLosky R J Astor B C Fox C H Vassalotti J A (2014) Primary care detection of chronic kidney disease in adults with type 2 diabetes The ADD-CKD Study (Awareness Detection and Drug Therapy in type 2 diabetes and chronic kidney disease PLOS doihttpsdoiorg101371journalpone0110535
bull USRDS (2016) Annual data report 2016 Epidemiology of kidney disease in the United States Retrieved from United States Renal Data System httpswwwusrdsorgadraspx
bull Vasudev B amp Vasudev M (2012) A model curriculum for residents rotating in nephrology MedEDPORTAL doihttpdoiorg1015766mep_2374-82658288
bull Wei L MacDonald T M Jennings C Sheng X amp Flynn R W (2013) Estimated GFR reporting is associated with decreased nonsteroidal anti-inflammatory drug prescribing and increased renal function Kidney International (84)1 174-178
chronic kidney disease in primary care
CKD as a Public Health Issue
Slide Number 3
Costs of CKD in 2013 dollarsUSRDS report
Steps to CKD Patient Care
Renal anatomy and physiology
Definition of Chronic Kidney Disease
CKD Risk Factors
Gaps in CKD Diagnosis
Slide Number 10
Steps to CKD Patient Care
creatinine
Glomerular filtration rate
Slide Number 14
Slide Number 15
Use These Equations Cautiously if at all in hellip
lab albumin creatinine ratio
The New CKD Categories
Steps to CKD Patient Care
Slide Number 20
Kidney Involvement in Systemic Diseases
Slide Number 22
Slide Number 23
DysmorphicRenal Hematuria
Slide Number 25
If you have albuminuria or hematuria-order the following labs
Prevalence of Abnormalities of Mineral Metabolism PTH in CKD
Managing CKD-MBD complications
CKD-MBD Testing
Anemia Becomes More Common as Kidney Function Declines
Detect and Manage CKD Complications
Complications-metabolic acidosis
Complications-vascular calcification
Hyperkalemia management
Hyperuricemia levels amp CKD
CKD monitoring levels 345
Slide Number 59
When to Refer to a Nephrologist
When to Refer
Steps to CKD Patient Care
Kidney transplantation
Starting Dialysis in the ElderlyhellipOr Not
Ckd management
Case 1
Slide Number 67
Lab results
Slide Number 69
Hypertensive nephropathy with proteinuria
Slide Number 71
Case 2
Slide Number 73
Management of CKD in Diabetes
Case 3
Case 3
Systemic Lupus Erythematosus (SLE)
SLE ndash Lupus Nephritis
Case 5
Case 5
Slide Number 81
Slide Number 82
Case study
Slide Number 84
CXR ndash Hilar Lymphadenopathy
Whats needed next
Slide Number 87
newly dx ckd
Slide Number 89
Bibliography
bibliography
bibliography
bibliography
bibliography
Stage 12
Stage 3
Stage 4
Stage 5
Hb le10 gdL
52
56
11
272
Hb gt10-le12 gdL
216
359
426
483
Hb le12 gdL
267
416
536
755
Stage 12
Stage 3
Stage 4
Stage 5
GLOMERULAR FILTRATION RATE
bull GFR is equal to the sum of the filtration rates in all of the functioning nephrons
bull Glomeruli filter 180Lday (125mLmin) of plasma
bull Normal GFR depends on age sex body size and is approximately 130mLmin for men and 120mLmin for womenmdashwith considerable variation
bull CKD-EPI equation (estimated GFR in mLmin173m2) is most accurate
Age Gender RaceSCr
(mgdL) eGFR (mLmin173 m2)
20 M B 13 91
20 M W 13 75
55 M W 13 61
20 F W 13 56
55 F B 13 55
50 F W 13 46
B = black W = all ethnic groups other than blackWith evidence of kidney damage
(Duncan Heathcoat Djurdjev amp Levin 2001)(National Kidney Foundation 2002)
or lt 15 mLmin173m2
(Levey et al 2009)
True GFR could be gt 70 mLmin173m2
The ldquoerdquo in eGFR Stands for ldquoEstimatedrdquohellip
USE THESE EQUATIONS CAUTIOUSLY IF AT ALL IN hellip
bull Patients who haveare
bull Poor nutritionloss of muscle mass
bull Amputation
bull Chronic illness
bull Not African American or Caucasian
bull Changing serum creatinine
bull Obese
bull Very elderly young
(National Kidney Foundation 2014)
LAB ALBUMIN CREATININE RATIO
bull Urinary albumin-to-creatinine ratio (ACR) is calculated by dividing albumin concentration in milligrams by creatinine concentration in grams
bull Creatinine assists in adjusting albumin levels for varying urine concentrations which allows for more accurate results versus albumin alone
bull Spot urine albumin-to-creatinine ratio for quantification of proteinuria
bull New guidelines classify albuminuria as mild moderately or severely increased
bull First morning void preferable
bull 24hr urine test rarely necessary
THE NEW CKD CATEGORIES
STEPS TO CKD PATIENT CARE
1 CKD definition and risks2 Assess GFR albuminuria3 Determine etiology- what is going on here4 Slow progression5 Assess for associated complications6 Discuss dialysistransplantation
(Pal 2012)
KIDNEY INVOLVEMENT IN SYSTEMIC DISEASES
Hypertension
DiabetesAmyloidosis
Sickle cell diseases
Immune complex GN
Illicit drugs ndash cocaine heroin
Cholesterol emboli
HIV
Allergic reactions- drugsinterstitial nephritis
Hemolytic Uremic syndrome
Lupus
Systemic vasculitis
Liver FailureCongestive heart Failure
Image retrieved on 05 October 2010 from httpenwikipediaorgwikiFileGray1129pngThis image is under the public domain and not copyrightable in the US as per Bridgeman Art Library v Corel Corp
(Vasudev amp Vasudev 2012)
New CKD
Obtain ultrasound UA
microscopy albumincr ratio
Ultrasound shows
obstruction
bull Yes Relieve obstruction
bull No Is there albuminuria or glomerular bleeding (eval for glomerulo-nephritis
Fatehi amp Chi-yuan 2016
If red cells have their typical shape and color this indicates extra glomerular hematuria
Examples kidney stone disease UTI cystitis bleeding from collecting duct ureters bladder or urethra
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileReactive_lymphJPGCreative Commons License associated httpcreativecommonsorglicensesby-sa30deeden
(Vasudev amp Vasudev 2012)
DYSMORPHICRENAL HEMATURIA
bull This hematuria is characterized by bull a great variation in the size of the cells and by a high
percentage of dysmorphocytosiscasts (gt20)
bull Hematuria is usually related to glomerular bleeding bull It is typically accompanied by variable levels of albumuniuria
(Vasudev amp Vasudev 2012)
Urinary Cast Formation
Urine Microscopy can be helpful in work up of chronic kidney disease
In GNrsquos the red blood cells leak from the glomerulus into the tubules As they traverse through the tubules they can form cylindrical casts calledRBC casts
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileRedbloodcellsjpgThis image is a work of the National Institutes of Health part of the United States Department of Health and Human Services As a work of the US federal government the image is in the public domain
(Vasudev amp Vasudev 2012)
IF YOU HAVE ALBUMINURIA OR HEMATURIA-ORDER THE FOLLOWING LABS
Tests of autoimmunity Hepatitis serologies gt40 years- paraproteinassessment
ANA Hepatitis B serology (HBsAG)
Serum protein electrophoresis (SPEP)
RFanti-ccp Hepatitis C serology(HCV antibody)
Urine protein electrophoresis (UPEP)
Complement C3 C4
ANCANational Kidney Disease Education Program 2014 NIH
UPTODATE LAB RECOMENDATIONS
bull Lab to order cbc cmp urine albumincr ratio urine microscopy
bull Nephrotic pattern (protein gt35gday) ANA anti DS DNA C3 and C4 antibodies HIV HBV HCV serumurine immunofixation (amyloidosis) free light chain analysis (light chain deposition disease)
bull Nephritic pattern (red cells white cells casts variable protein) C3 C4 ANA dsDNA antineutrophil cytoplasmic antibody (ANCA) titers a streptozyme test HBV and HCV serologies HIV and in some cases blood cultures anti-glomerular basement membrane (GBM) antibodies and cryoglobulins
bull Renal biopsy(Hebert amp Parikh 2014)
EVALUATION OF NEW CKDNO OBSTRUCTION
NO EVIDENCE OF GLOMERULAR BLEEDING
High risk for multmyeloma (gt40
no nsaids no contrast
SPEP UPEP with immunofixation serum free light
chains
Evaluation depends on UA
Sterile pyuria
Eval for interstitial nephritis
Normal urinalysis
High risk for renovascular
disease
Eval for renovascular
disease
Follow serum creatinine-does it
remain stable(Fatehi amp Chi-yuan 2016)
POSSIBLE INVESTIGATIONShellip
Acute interstitial nephritisbull Drugs are the most common cause of AIN
DIABETIC NEPHROPATHY 1 CAUSE OF CKDbull Clinical syndromebull Albuminuria gt30 mg 24 hrsbull Proteinuria gt500 mg24 hrsbull Hypertension developsbull Progressive increase in proteinuriabull Progressive decline in glomerular filtration rate
bull Chronic kidney disease should be attributed to diabetic nephropathies in most patients with diabetes if albuminuria and diabetic retinopathy are both present other causes of CKD should be entertained if diabetic retinopathy is absent (KDIGO 2007)
DIABETIC NEPHROPATHY MORTALITY
bull After 40 yrs of DM
bull 10 alive if proteinuria is present
bull 70 alive if proteinuria is absent
bull Heart Disease is 15 times higher risk in those with proteinuria
bull Proteinuria = death in this population
Dunkler et al 2015
GOALS OF CARE IN CKD GLUCOSE CONTROL
bull Target HbA1c ~70 (lt695 greatest chance of reducing albuminuria)bull Can be extended above 70 with comorbidities or limited life expectancy and
risk of hypoglycemiabull Risk of hypoglycemia increases as kidney function becomes impairedbull Declining kidney function may necessitate changes to diabetes medications and
bull Just having HTN can cause proteinuriabull Usually 1-2 gms of protein a daybull Treat them like a diabetic with ACEI or ARBS and tight blood
pressure controlbull JNC-8 goal lt14090 for ptrsquos with CKDbull National kidney foundation lt14090 if ckd and no proteinuria
lt13080 if proteinuria present
(James Ortiz amp Et Al 2014)
TREATING HYPERTENSIONPROTEINURIA ACEI ORARBbull Riskbenefit should be carefully assessed in the elderly and medically fragilebull Check labs after initiation
bull If less than 30 SCr increase continue and monitorbull If more than 30 SCr increase stop ACEi and evaluate for renal artery stenosis
bull Continue until contraindication arises no absolute eGFR cutoffbull Better proteinuria suppression with low Na diet and diureticsbull Avoid volume depletionbull Avoid ACEi and ARB in combination12
bull Risk of adverse events (impaired kidney function hyperkalemia)
(Kunz Friedrich Wolbers amp Mann 2008)(Mann Schmieder amp McQueen 2008)
bull In adults gt50 yrs statin when eGFR ge 60 mlmin173m2 statin or statinezetimibe combination when eGFR lt 60 mlmin173m2
bull In adults lt 50 yrs statin if history of known CAD MI DM strokebull Aspirin is indicated for secondary but not primary prevention
Kidney Disease Improving Global Outcomes (KDIGO) CKD Work Group Kidney Int Suppls 201331-150
STATINS-RENOPROTECTIVECONTROVERSY
bull HMG-CoA reductase inhibitors (statins) in high doses can cause proteinuria
bull Possibly associated with less inflammation endothelial dysfunction and scarring in the kidney because they also block inflammatory cytokines
bull Use statins for CV disease not to treat proteinuria
(Afzali and Goldsmith 2016)
MEDICINE CAUTION
bull Hold metformin when gfr lt35 mlmin
bull GFR lt50 mlmin should alert to check all doses of meds
bull No bisphosphanates lt35 mlmin
bull No NSAIDScox 2 inhibitors lt60 mlmin
bull Atenolol ndashrenal excretion
bull BACTRIM A lot of AKI
MEDICINE CAUTION
bull Lovenox-use subcut heparinbull Apixibanbull Dabigatranbull Rivaroxibanbull Lithiumbull GABAPENTIN (ckd 4 max 300mg qd ckd 5 max 300mg qod)
STEPS TO CKD PATIENT CARE
1 CKD definition and risks2 Assess GFR albuminuria3 Determine etiology4 Assess for evidence of progression5 Assess for associated complications6 Discuss dialysistransplantation
CKD-CVD-DIABETES LINK CKD IS A DISEASE MULTIPLIER
National kidney foundation 2014
KDIGO 2017
CKD-MINERAL BONE DISORDERS
bull As kidneys fail they
bull Stop activating calcitriol (the active form of Vit D)mdashcausing calcium imbalance
bull Do not remove phosphorus from bloodmdashleading to phosphorus retention
bull The extra phosphorus pulls calcium out of bones causing them to weaken
bull High phosphorus stimulates PTH release
bull These changes (plus others) cause the start of secondary hyperparathyroidism
bull Labs
bull eGFR
bull Calcium
bull Phos
bull Vit D
bull iPTH
(Qunibi amp Henrich 2017)
PREVALENCE OF ABNORMALITIES OF MINERAL METABOLISM PTH IN CKD
bull Progression of disease ndash declining eGFR increasing proteinuria
bull Degree of proteinuria nephrotic syndrome gt 05-10 gd on ACEi or ARB therapy
bull Etiology of CKD not certain
bull Need help with disease management
bull Indications for kidney biopsy
Rosenberg 2016
WHEN TO REFER
STEPS TO CKD PATIENT CARE
1 CKD definition and risks2 Assess GFR albuminuria3 Determine etiology4 Assess for evidence of progression5 Assess for associated complications6 Discuss dialysistransplantation
KIDNEY TRANSPLANTATION
bull Treatment of choice for ESRDbull Improves quality of lifebull Waiting list time varies-3-5 yearsbull 3 year survival rate after transplantation is 83-94bull Increased risk of cancer
STARTING DIALYSIS IN THE ELDERLYhellipOR NOT
bull Among patients gt 75 yrs with stage 5 CKD who chose to NOT start dialysisbull Overall more likely to die over next 1-2 years bull But if they had ischemic heart disease or other significant comorbidity NO
DIFFERENCE in survival
bull Active disease management and supportive care may be appropriate without starting dialysis in the ill elderly
bull Palliative care does not mean ldquono carerdquo
bull Must have end-of-life discussions
(Murtagh et al 2007)
CKD MANAGEMENTbull Diagnose cause and treat underlying conditionbull Stage per guidelinesbull Slow progression of kidney disease (ACE inhibitors)bull Monitor for complicationsmdashvolume overload hyperkalemia metabolic acidosis
hyperphosphatemia anorexia fatigue htn bone diseasebull Labs cmp cbc phos Vit D 25OH iPTH urine microscopy uric acid urine
proteincr ratio-frequency based off heat map Get sono at least oncebull Vaccinate influenza hep B pneumococcalbull Eval ASCVD risk-likely needs statinbull Possible dexa (donrsquot give bisphosphonates if GFRlt35 let specialist manage)bull Refer to nephrology when eGFR is lt30 (sometimes if higher risk-refer earlier)
CASE 1
bull 55 year old man with past medical history of headaches presents to your office for his first time visit to a PCP in over 30 years
bull He has no past history of being admitted to the hospital and he does not take any OTC medsNSAIDsherbal meds He has no history of ETOH abuse smoking or drug use
bull Vitals BP 180100 mmHg pulse 80 R 18
bull Exam No JVD S1S2 regular PMI shifted to the left no gallop no abdominal bruit pulses bilaterally equal and regular no leg edema
bull What would you order
bull EKG cbc cmp ua urine proteincr ratio lipid
LAB RESULTS
bull Labs reveal a creatinine of 22 mgdL eGFR 33 Urine shows no blood or casts Urineprotein ratio shows 1 gm protein24 hrs EKG shows LVH
bull Next step in workupbull Renal ultrasound 1st then SPEP UPEP with immunofixation serum free light chains
bull Additional labs neg Renal ultrasound shows that both kidneys are slightly reduced in size and are mildly echogenic with no mass or hydronephrosis
bull What is your diagnosis
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileMain_complications_of_persistent_high_blood_pressurepngCreative Commons License associated httpcreativecommonsorglicensesby-sa30
bull 3 months Howevermdashwe have evidence of structural abnormalities Could potentially stage at G3b A3 (red on the heat map)
bull Goal blood pressure
bull JNC 8 14090 NKF 13080
bull Additional lab needed for progression monitoring
bull Cbc renal panel phos Vit D iPTH uric acid urine micro (we already have the renal sono and urine proteincr ratio and lipid)
Selective renal angiography (left lower renal artery) after successful percutaneous balloon dilatation of the stenotic lesionFibromuscular dysplasia in an accessory renal artery causing renovascular hypertension
Secondary Hypertension
Images retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileRenal_FMD2jpg and httpcommonswikimediaorgwikiFileRenal_FMDjpgCreative Commons License associated httpcreativecommonsorglicensesby20deeden (both images)
CASE 2bull OS is a 64year old Hispanic female in for DM check She has had DM for 15+ years and is currently
taking metformin 1000mg bid Lisinopril 10mg a day atorvastatin 40mg a day Labs today showed the following
bull Hgba1c 86 cmp eGFR 50 lipid WNL proteincr ratio 650mg These results are similar to her last visit
bull Upon further hx-you find that she had a recent eye exam and has mild nonproliferaive retinopathy She does not have neuropathy or other ss
bull What further workup do you need
bull Renal sonogram urine micro iPTH vit D (25 OH) phos uric acid
bull Dx stage
bull G3a A3
bull What further treatment do you need
bull Improve glycemic control Increase Lisinopril to 20mg with a goal of 40mg Avoid NSAIDs or other nephrotoxic agents make sure meds are renally dosed monitor 3xyear nephro referral
MANAGEMENT OF CKD IN DIABETESeGFR Recommended
All patients
Yearly measurement of creatinine urinary albumin excretion potassium
45-60 Referral to a nephrologist if possibility for nondiabetickidney disease existsConsider dose adjustment of medicationsMonitor eGFR every 6 monthsMonitor electrolytes bicarbonate hemoglobin calcium phosphorus parathyroid hormone at least yearly
Assure vitamin D sufficiencyConsider bone density testingReferral for dietary counselling
American Diabetes Association Standards of Medical Care in Diabetes Microvascular complications and foot care Diabetes Care 2017 40 (Suppl 1) S88-S98
CASE 3
bull 19 year old African American woman presents to your clinic with complaints of fatigue joint pains a new rash on her face oral ulcer
bull On exam BP 15080 P 88 Afebrile 96 O2 sats on RAbull GEN No respiratory distress at restbull HEENT painless oral ulcer flat rash over malar eminences sparing the nasolabial fold pallor +bull Lungs CTAbull CVS S1S2 regularbull Abdomen soft NTbull Ext left elbow joint and bilateral wrist joints are swollen and tender
bull What would you orderbull CBC CMP ua urine microscopy (microalbumin or urine proteincr ratio) ANA esr RF anti-ccp uric acid TSH
CASE 3
bull Working dx fatigue oral ulcer joint pain
bull Basic Labs Na 135 K 55 Bicarb 18 BUN 50 Cr 35 eGFR 22 Ca 90 ANA + titer 1640
bull UA 3+ blood 3+ protein RBC casts +
bull Given these results what is the most likely diagnosis
bull What would you do
SYSTEMIC LUPUS ERYTHEMATOSUS (SLE)
bull SLE multisystemic disease Etiology unknown
bull Production of autoantibodies and immune complexes formation
bull There is renal involvement in the great majority of patients with SLE at some time of the evolution 66-90
SLE ndash LUPUS NEPHRITIS
bull Race SLE is more commonsevere in African americans than Caucasiansbull
bull Gender female-to-male ratio of 91
bull Age Most patients develop lupus nephritis early in their disease course SLE is more common among women in the third decade of life and lupus nephritis occurs in patients aged 20-40 years
bull Kidney Biopsy For staging lupus nephritis (Class 1-5)
CASE 5bull A 80 year old man who has not seen a PCP in many years
presents to your clinic for weakness for the past few months On further questioning he tells you that his bones also have been hurting lately and he has developed leg swelling in the past month or so
bull On exam bull BP 16090 P 88 Afebrilebull GEN Thin built manbull HEENT pallor presentbull Lungs clearbull CVS S1S2 regular no rub or gallopbull Abdomen soft NTbull Ext 2 + edema
CASE 5
bull Differentials
bull CHF MI Cancer arthritis
bull Labs
bull CBC CMP urine microscopy urine proteincr ratio ESR TSH EKG BNP pa and lat CXR
bull LABS Urine dipstick negative for protein or blood
bull Basic chem bull Na 136 (135-145) K 51 (35-55) Chloride 108 (96-106) Bicarb 25
Given this presentation and the labs (low anion gap and elevated calcium anemia kidney failure) what will you think of What will you order next
Serum and urine protein electrophoresis
Intratubular refractile casts with surrounding syncytial giant cell reaction with chronic tubulointerstitial nephritis and fibrosis characteristic of myeloma cast nephropathy
Kidney Biopsy
CASE STUDYbull A 35 year old African American woman was seen in the clinic for
chronic cough and dyspnea on exertion She gave history of vague symptoms of fatigue and weight loss of 20 Ibs over the last six months
bull List some differentialsbull TB sarcoid lupus thyroid problems PEbull What would you orderbull PPD cbc cmp UA TSH ANA pa and lat cxr
bull Her labs were significant for mildly elevated calcium level and a creatinine of 20 mgdL eGFR 37
bull She had 750 mg of proteinuriaday
bull PPD neg ANA neg TSH and other labs WNL
bull Assuming this is present more than 3 monthshelliphellipwhat is her ckd stage
bull G3b A3
bull What do we still need
CT scan of chest
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileAnterior_mediastinal_mass_thymomajpgCreative Commons License associated httpcreativecommonsorglicensesby20deeden
CXR ndash HILAR LYMPHADENOPATHY
WHATS NEEDED NEXT
bull Biopsy of hilar lymphadenopathy or renal biopsy
bull DX sarcoidosis
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileSarcoidosis_signs_and_symptomsjpgThis work is in the public domain in the United States because it is a work of the United States Federal Government under the terms of Title 17 Chapter 1 Section 105 of the US Code
NEWLY DX CKD
bull 1) urinalysis microscopy ultrasound proteincr ratio
bull If obstruction-treat
bull No obstruction
bull Hx critical (consider myeloma if high risk)
bull glomerular bleeding or albumin in urine
bull Yes workup for glomerular causes (ANArf hep B C upep spep ANCA complement C3 C4)
bull No sterile pyruria-consider interstitial nephritis
bull High risk renovascular disease Evaluate renovascular disease
Additional Online Resources for CKD LearningbullNational Kidney Foundation wwwkidneyorgbullUnited States Renal Data Service wwwusrdsorgbullCDCrsquos CKD Surveillance Project
httpnccdcdcgovckdbullNational Kidney Disease Education Program
(NKDEP) httpnkdepnihgov
BIBLIOGRAPHY
bull Afzali B amp Goldsmith D J (2016 June 29) Statins and chronic kidney disease (G C Curhan amp A M Sheridan Eds) Retrieved 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsstatins-and-chronic-kidney-disease
bull American Diabetes Association Standards of Medical Care in Diabetes (2017) Microvascular complications and foot care Diabetes Care 2017 (40) S88-S98
bull American Diabetes Association Standards of Medical Care in Diabetes (2017) Microvascular complications and foot care Diabetes Care 40 (suppl 1) S88-S98
bull Berns J S (2017 Mar 22) Treatment of anemia in nondialysis chronic kidney disease (T A Golper amp A M Sheridan Eds) Retrieved from UpToDate httpswww-uptodate-comproxywichitaeducontentstreatment-of-anemia-in-nondialysis-chronic-kidney-disease
bull Chan M Dall A T Fletcher K E Lu N amp Trivedi H (2007) Outcomes in patients with chronic kidney disease referred late to nephrologists a meta-analysis American Journal of Medicine 120(12) 1063-1070
bull Coresh J Selvin E amp Stevens L A (2007) Prevalence of chronic kidny disease in the United States JAMA 298(17) doi101001jama298172038
bull de Brito-Ashurst I Varagunam M Raftery M amp Yagoob M (2009) Bicarbonate supplementation slows progression of CKD and improves nutritional status Journal of American Society of Nephrology (20) 2075-2084
BIBLIOGRAPHY
bull Duncan L Heathcoat J Djurdjev O amp Levin A (2001) Screening for renal disease using serum creatinine who are we missing Nephrology Dialysis and Transplant 16(5) 1042-1046
bull Dunkler D Gao P Lee S F Heinz G Clase C M Tobe S Oberbauer R (2015 August 7) Risk prediction for early CKD in type 2 diabetes Retrieved from Clinical Journal of the American Society of Nephrology httpcjasnasnjournalsorgcontent1081371fullsid=61422554-a5f1-41ac-b696-dcd3b12bd268
bull Fatehi P amp Chi-yuan H (September 15 2016) Diagnostic approach to the patient with newly identified chronic kidney disease (G C Curhan amp A M Sheridan Eds) Retrieved May 7 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsdiagnostic-approach-to-the-patient-with-newly-identified-chronic-kidney-disease
bull Fink J e (2009) Chronic Kidney Disease as an Under-Recognized Threat to Patient Safety American journal of kidney diseases the official journal of the National Kidney Foundation 53(4) 681-688
bull Gaffo A L amp Saag K G (2008 Nov) Management of hyperuricemia and gout in CKD doihttpdxdoiorg101053jajkd200807035
bull Hebert L A amp Parikh S V (2014 June 18) Differential diagnosis and evaluation of glomerular disease (R J Glassock amp A Q Lam Eds) Retrieved May 7 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsdifferential-diagnosis-and-evaluation-of-glomerular-disease
bull Inker L Perrone R D Sterns R H amp Forman J P (2017 March 7) Assessment of kidney function Retrieved from UpToDate httpswww-uptodate-comproxywichitaeducontentsassessment-of-kidney-functionsource=search_resultampsearch=creatinineampselectedTitle=1~150
BIBLIOGRAPHY
bull James P A Ortiz E amp Et Al (2014) Evidence based guideline for the management of high blood pressure in adults (JNC) JAMA 311(5) 507-520
bull Kidney Disease Improving Global Outcomes (KDIGO) CKD Work Group (2013 January) KDIGO 2012 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease Retrieved from Kidney International Supplement httpwwwkidney-internationalorg
bull Kunz R Friedrich C Wolbers M amp Mann J F (2008) Meta-analysis effect of monotherapy and combination therapy with inhibitors of the renin angiotensin system on proteinuria in renal disease Annals of Internal Medicine 148(1) 30-48
bull Levey A Stevens L A Schmid C H Castro A F Feldman H I Kusek J W Coresh J (2009) A new equation to estimate glomerular filtration rate Annals of Internal Medicine 150(9) 604-612
bull Levin A Bakris G L Molitch M Smulders M M Williams L A amp Andress D L (2007 Jan) Prevalence of abnormal serum vitamin D PTH calcium and phosphorus in patients with chronic kidney disease results of the study to evaluate early kidney disease Kidney International 71(1) 31-38 Retrieved from PubMED
bull Mahajan A Simoni J Sheather S Broglio K Rajab M amp Wesson D (2010) Daily oral sodium bicarbonate preserves glomerular filtration rate by slowing its decline in early hypertensive nephropathy Kidney International (78_ 303-309
bull Mann J Schmieder R E amp McQueen M (2008) Renal outcomes with telmisartan ramipril or both in people at high vascular risk (the ONTARGET study) a multicentre randomised doubleblind ocntrolled trial Lancet 372(9638) 547-533
BIBLIOGRAPHY
bull Matovinović M S (2009) Pathophysiology and classification of kidney disease Retrieved from The Journal of the International Federation of Clinical Chemistry and Laboratory Medicine httpwwwifccorgifccfilesdocs20010902pdf
bull Moe S Drueke T Lameire N amp Eknoyan G (2007 Jan) Chronic kidney disease-mineral-bone disorder a new paradigmdoi101053jackd200610005
bull Murtagh F E Marsh J E Donohoe P Ekbal N J Sheerin N S amp Harris F E (2007 July) Dialysis or not A comparative survival study of patients over 75 years with chronic kidney disease stage 5 Retrieved from Nephrology Dialysis and Transplant 22(7) httpswwwncbinlmnihgovpubmed17412702
bull National Kidney Foundation (2002) KDOQI clinical practice guidelines for chronic kidney disease evaluation classification andstratification American Journal of Kidney Disease S1-S266
bull National Kidney Foundation (2014 November 5) Fact Sheets Retrieved from httpwwwkidneyorgnewsnewsroomfactsheetsFastFacts
bull Pal S (2012 June 2) Trends in chronic kidney disease Retrieved from US Pharmacist (37)6 httpswwwuspharmacistcomarticletrends-in-chronic-kidney-disease
bull Qunibi W amp Henrich W L (2017 Jan 19) Overview of chronic kidney disease-mineral and bone disorder (J Berns amp A M Sheridan Eds) Retrieved from UpToDate httpswww-uptodate-comoverview-of-chronic-kidney-disease-mineral-and-bone-disorder-ckd-mbd
bull Rosenberg M (2016 Feb 24) Overview of the management of chronic kidney disease in adults (G C Curhan amp A M Sheridan Eds) Retrieved from UpToDate UpToDate httpswww-uptodate-comproxywichitaeducontentsoverview-of-the-management-of-chronic-kidney-disease-in-adults
BIBLIOGRAPHY
bull Szczech L Stewart R C Hsu-Lin S DeLosky R J Astor B C Fox C H Vassalotti J A (2014) Primary care detection of chronic kidney disease in adults with type 2 diabetes The ADD-CKD Study (Awareness Detection and Drug Therapy in type 2 diabetes and chronic kidney disease PLOS doihttpsdoiorg101371journalpone0110535
bull USRDS (2016) Annual data report 2016 Epidemiology of kidney disease in the United States Retrieved from United States Renal Data System httpswwwusrdsorgadraspx
bull Vasudev B amp Vasudev M (2012) A model curriculum for residents rotating in nephrology MedEDPORTAL doihttpdoiorg1015766mep_2374-82658288
bull Wei L MacDonald T M Jennings C Sheng X amp Flynn R W (2013) Estimated GFR reporting is associated with decreased nonsteroidal anti-inflammatory drug prescribing and increased renal function Kidney International (84)1 174-178
chronic kidney disease in primary care
CKD as a Public Health Issue
Slide Number 3
Costs of CKD in 2013 dollarsUSRDS report
Steps to CKD Patient Care
Renal anatomy and physiology
Definition of Chronic Kidney Disease
CKD Risk Factors
Gaps in CKD Diagnosis
Slide Number 10
Steps to CKD Patient Care
creatinine
Glomerular filtration rate
Slide Number 14
Slide Number 15
Use These Equations Cautiously if at all in hellip
lab albumin creatinine ratio
The New CKD Categories
Steps to CKD Patient Care
Slide Number 20
Kidney Involvement in Systemic Diseases
Slide Number 22
Slide Number 23
DysmorphicRenal Hematuria
Slide Number 25
If you have albuminuria or hematuria-order the following labs
Prevalence of Abnormalities of Mineral Metabolism PTH in CKD
Managing CKD-MBD complications
CKD-MBD Testing
Anemia Becomes More Common as Kidney Function Declines
Detect and Manage CKD Complications
Complications-metabolic acidosis
Complications-vascular calcification
Hyperkalemia management
Hyperuricemia levels amp CKD
CKD monitoring levels 345
Slide Number 59
When to Refer to a Nephrologist
When to Refer
Steps to CKD Patient Care
Kidney transplantation
Starting Dialysis in the ElderlyhellipOr Not
Ckd management
Case 1
Slide Number 67
Lab results
Slide Number 69
Hypertensive nephropathy with proteinuria
Slide Number 71
Case 2
Slide Number 73
Management of CKD in Diabetes
Case 3
Case 3
Systemic Lupus Erythematosus (SLE)
SLE ndash Lupus Nephritis
Case 5
Case 5
Slide Number 81
Slide Number 82
Case study
Slide Number 84
CXR ndash Hilar Lymphadenopathy
Whats needed next
Slide Number 87
newly dx ckd
Slide Number 89
Bibliography
bibliography
bibliography
bibliography
bibliography
Stage 12
Stage 3
Stage 4
Stage 5
Hb le10 gdL
52
56
11
272
Hb gt10-le12 gdL
216
359
426
483
Hb le12 gdL
267
416
536
755
Stage 12
Stage 3
Stage 4
Stage 5
Age Gender RaceSCr
(mgdL) eGFR (mLmin173 m2)
20 M B 13 91
20 M W 13 75
55 M W 13 61
20 F W 13 56
55 F B 13 55
50 F W 13 46
B = black W = all ethnic groups other than blackWith evidence of kidney damage
(Duncan Heathcoat Djurdjev amp Levin 2001)(National Kidney Foundation 2002)
or lt 15 mLmin173m2
(Levey et al 2009)
True GFR could be gt 70 mLmin173m2
The ldquoerdquo in eGFR Stands for ldquoEstimatedrdquohellip
USE THESE EQUATIONS CAUTIOUSLY IF AT ALL IN hellip
bull Patients who haveare
bull Poor nutritionloss of muscle mass
bull Amputation
bull Chronic illness
bull Not African American or Caucasian
bull Changing serum creatinine
bull Obese
bull Very elderly young
(National Kidney Foundation 2014)
LAB ALBUMIN CREATININE RATIO
bull Urinary albumin-to-creatinine ratio (ACR) is calculated by dividing albumin concentration in milligrams by creatinine concentration in grams
bull Creatinine assists in adjusting albumin levels for varying urine concentrations which allows for more accurate results versus albumin alone
bull Spot urine albumin-to-creatinine ratio for quantification of proteinuria
bull New guidelines classify albuminuria as mild moderately or severely increased
bull First morning void preferable
bull 24hr urine test rarely necessary
THE NEW CKD CATEGORIES
STEPS TO CKD PATIENT CARE
1 CKD definition and risks2 Assess GFR albuminuria3 Determine etiology- what is going on here4 Slow progression5 Assess for associated complications6 Discuss dialysistransplantation
(Pal 2012)
KIDNEY INVOLVEMENT IN SYSTEMIC DISEASES
Hypertension
DiabetesAmyloidosis
Sickle cell diseases
Immune complex GN
Illicit drugs ndash cocaine heroin
Cholesterol emboli
HIV
Allergic reactions- drugsinterstitial nephritis
Hemolytic Uremic syndrome
Lupus
Systemic vasculitis
Liver FailureCongestive heart Failure
Image retrieved on 05 October 2010 from httpenwikipediaorgwikiFileGray1129pngThis image is under the public domain and not copyrightable in the US as per Bridgeman Art Library v Corel Corp
(Vasudev amp Vasudev 2012)
New CKD
Obtain ultrasound UA
microscopy albumincr ratio
Ultrasound shows
obstruction
bull Yes Relieve obstruction
bull No Is there albuminuria or glomerular bleeding (eval for glomerulo-nephritis
Fatehi amp Chi-yuan 2016
If red cells have their typical shape and color this indicates extra glomerular hematuria
Examples kidney stone disease UTI cystitis bleeding from collecting duct ureters bladder or urethra
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileReactive_lymphJPGCreative Commons License associated httpcreativecommonsorglicensesby-sa30deeden
(Vasudev amp Vasudev 2012)
DYSMORPHICRENAL HEMATURIA
bull This hematuria is characterized by bull a great variation in the size of the cells and by a high
percentage of dysmorphocytosiscasts (gt20)
bull Hematuria is usually related to glomerular bleeding bull It is typically accompanied by variable levels of albumuniuria
(Vasudev amp Vasudev 2012)
Urinary Cast Formation
Urine Microscopy can be helpful in work up of chronic kidney disease
In GNrsquos the red blood cells leak from the glomerulus into the tubules As they traverse through the tubules they can form cylindrical casts calledRBC casts
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileRedbloodcellsjpgThis image is a work of the National Institutes of Health part of the United States Department of Health and Human Services As a work of the US federal government the image is in the public domain
(Vasudev amp Vasudev 2012)
IF YOU HAVE ALBUMINURIA OR HEMATURIA-ORDER THE FOLLOWING LABS
Tests of autoimmunity Hepatitis serologies gt40 years- paraproteinassessment
ANA Hepatitis B serology (HBsAG)
Serum protein electrophoresis (SPEP)
RFanti-ccp Hepatitis C serology(HCV antibody)
Urine protein electrophoresis (UPEP)
Complement C3 C4
ANCANational Kidney Disease Education Program 2014 NIH
UPTODATE LAB RECOMENDATIONS
bull Lab to order cbc cmp urine albumincr ratio urine microscopy
bull Nephrotic pattern (protein gt35gday) ANA anti DS DNA C3 and C4 antibodies HIV HBV HCV serumurine immunofixation (amyloidosis) free light chain analysis (light chain deposition disease)
bull Nephritic pattern (red cells white cells casts variable protein) C3 C4 ANA dsDNA antineutrophil cytoplasmic antibody (ANCA) titers a streptozyme test HBV and HCV serologies HIV and in some cases blood cultures anti-glomerular basement membrane (GBM) antibodies and cryoglobulins
bull Renal biopsy(Hebert amp Parikh 2014)
EVALUATION OF NEW CKDNO OBSTRUCTION
NO EVIDENCE OF GLOMERULAR BLEEDING
High risk for multmyeloma (gt40
no nsaids no contrast
SPEP UPEP with immunofixation serum free light
chains
Evaluation depends on UA
Sterile pyuria
Eval for interstitial nephritis
Normal urinalysis
High risk for renovascular
disease
Eval for renovascular
disease
Follow serum creatinine-does it
remain stable(Fatehi amp Chi-yuan 2016)
POSSIBLE INVESTIGATIONShellip
Acute interstitial nephritisbull Drugs are the most common cause of AIN
DIABETIC NEPHROPATHY 1 CAUSE OF CKDbull Clinical syndromebull Albuminuria gt30 mg 24 hrsbull Proteinuria gt500 mg24 hrsbull Hypertension developsbull Progressive increase in proteinuriabull Progressive decline in glomerular filtration rate
bull Chronic kidney disease should be attributed to diabetic nephropathies in most patients with diabetes if albuminuria and diabetic retinopathy are both present other causes of CKD should be entertained if diabetic retinopathy is absent (KDIGO 2007)
DIABETIC NEPHROPATHY MORTALITY
bull After 40 yrs of DM
bull 10 alive if proteinuria is present
bull 70 alive if proteinuria is absent
bull Heart Disease is 15 times higher risk in those with proteinuria
bull Proteinuria = death in this population
Dunkler et al 2015
GOALS OF CARE IN CKD GLUCOSE CONTROL
bull Target HbA1c ~70 (lt695 greatest chance of reducing albuminuria)bull Can be extended above 70 with comorbidities or limited life expectancy and
risk of hypoglycemiabull Risk of hypoglycemia increases as kidney function becomes impairedbull Declining kidney function may necessitate changes to diabetes medications and
bull Just having HTN can cause proteinuriabull Usually 1-2 gms of protein a daybull Treat them like a diabetic with ACEI or ARBS and tight blood
pressure controlbull JNC-8 goal lt14090 for ptrsquos with CKDbull National kidney foundation lt14090 if ckd and no proteinuria
lt13080 if proteinuria present
(James Ortiz amp Et Al 2014)
TREATING HYPERTENSIONPROTEINURIA ACEI ORARBbull Riskbenefit should be carefully assessed in the elderly and medically fragilebull Check labs after initiation
bull If less than 30 SCr increase continue and monitorbull If more than 30 SCr increase stop ACEi and evaluate for renal artery stenosis
bull Continue until contraindication arises no absolute eGFR cutoffbull Better proteinuria suppression with low Na diet and diureticsbull Avoid volume depletionbull Avoid ACEi and ARB in combination12
bull Risk of adverse events (impaired kidney function hyperkalemia)
(Kunz Friedrich Wolbers amp Mann 2008)(Mann Schmieder amp McQueen 2008)
bull In adults gt50 yrs statin when eGFR ge 60 mlmin173m2 statin or statinezetimibe combination when eGFR lt 60 mlmin173m2
bull In adults lt 50 yrs statin if history of known CAD MI DM strokebull Aspirin is indicated for secondary but not primary prevention
Kidney Disease Improving Global Outcomes (KDIGO) CKD Work Group Kidney Int Suppls 201331-150
STATINS-RENOPROTECTIVECONTROVERSY
bull HMG-CoA reductase inhibitors (statins) in high doses can cause proteinuria
bull Possibly associated with less inflammation endothelial dysfunction and scarring in the kidney because they also block inflammatory cytokines
bull Use statins for CV disease not to treat proteinuria
(Afzali and Goldsmith 2016)
MEDICINE CAUTION
bull Hold metformin when gfr lt35 mlmin
bull GFR lt50 mlmin should alert to check all doses of meds
bull No bisphosphanates lt35 mlmin
bull No NSAIDScox 2 inhibitors lt60 mlmin
bull Atenolol ndashrenal excretion
bull BACTRIM A lot of AKI
MEDICINE CAUTION
bull Lovenox-use subcut heparinbull Apixibanbull Dabigatranbull Rivaroxibanbull Lithiumbull GABAPENTIN (ckd 4 max 300mg qd ckd 5 max 300mg qod)
STEPS TO CKD PATIENT CARE
1 CKD definition and risks2 Assess GFR albuminuria3 Determine etiology4 Assess for evidence of progression5 Assess for associated complications6 Discuss dialysistransplantation
CKD-CVD-DIABETES LINK CKD IS A DISEASE MULTIPLIER
National kidney foundation 2014
KDIGO 2017
CKD-MINERAL BONE DISORDERS
bull As kidneys fail they
bull Stop activating calcitriol (the active form of Vit D)mdashcausing calcium imbalance
bull Do not remove phosphorus from bloodmdashleading to phosphorus retention
bull The extra phosphorus pulls calcium out of bones causing them to weaken
bull High phosphorus stimulates PTH release
bull These changes (plus others) cause the start of secondary hyperparathyroidism
bull Labs
bull eGFR
bull Calcium
bull Phos
bull Vit D
bull iPTH
(Qunibi amp Henrich 2017)
PREVALENCE OF ABNORMALITIES OF MINERAL METABOLISM PTH IN CKD
bull Progression of disease ndash declining eGFR increasing proteinuria
bull Degree of proteinuria nephrotic syndrome gt 05-10 gd on ACEi or ARB therapy
bull Etiology of CKD not certain
bull Need help with disease management
bull Indications for kidney biopsy
Rosenberg 2016
WHEN TO REFER
STEPS TO CKD PATIENT CARE
1 CKD definition and risks2 Assess GFR albuminuria3 Determine etiology4 Assess for evidence of progression5 Assess for associated complications6 Discuss dialysistransplantation
KIDNEY TRANSPLANTATION
bull Treatment of choice for ESRDbull Improves quality of lifebull Waiting list time varies-3-5 yearsbull 3 year survival rate after transplantation is 83-94bull Increased risk of cancer
STARTING DIALYSIS IN THE ELDERLYhellipOR NOT
bull Among patients gt 75 yrs with stage 5 CKD who chose to NOT start dialysisbull Overall more likely to die over next 1-2 years bull But if they had ischemic heart disease or other significant comorbidity NO
DIFFERENCE in survival
bull Active disease management and supportive care may be appropriate without starting dialysis in the ill elderly
bull Palliative care does not mean ldquono carerdquo
bull Must have end-of-life discussions
(Murtagh et al 2007)
CKD MANAGEMENTbull Diagnose cause and treat underlying conditionbull Stage per guidelinesbull Slow progression of kidney disease (ACE inhibitors)bull Monitor for complicationsmdashvolume overload hyperkalemia metabolic acidosis
hyperphosphatemia anorexia fatigue htn bone diseasebull Labs cmp cbc phos Vit D 25OH iPTH urine microscopy uric acid urine
proteincr ratio-frequency based off heat map Get sono at least oncebull Vaccinate influenza hep B pneumococcalbull Eval ASCVD risk-likely needs statinbull Possible dexa (donrsquot give bisphosphonates if GFRlt35 let specialist manage)bull Refer to nephrology when eGFR is lt30 (sometimes if higher risk-refer earlier)
CASE 1
bull 55 year old man with past medical history of headaches presents to your office for his first time visit to a PCP in over 30 years
bull He has no past history of being admitted to the hospital and he does not take any OTC medsNSAIDsherbal meds He has no history of ETOH abuse smoking or drug use
bull Vitals BP 180100 mmHg pulse 80 R 18
bull Exam No JVD S1S2 regular PMI shifted to the left no gallop no abdominal bruit pulses bilaterally equal and regular no leg edema
bull What would you order
bull EKG cbc cmp ua urine proteincr ratio lipid
LAB RESULTS
bull Labs reveal a creatinine of 22 mgdL eGFR 33 Urine shows no blood or casts Urineprotein ratio shows 1 gm protein24 hrs EKG shows LVH
bull Next step in workupbull Renal ultrasound 1st then SPEP UPEP with immunofixation serum free light chains
bull Additional labs neg Renal ultrasound shows that both kidneys are slightly reduced in size and are mildly echogenic with no mass or hydronephrosis
bull What is your diagnosis
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileMain_complications_of_persistent_high_blood_pressurepngCreative Commons License associated httpcreativecommonsorglicensesby-sa30
bull 3 months Howevermdashwe have evidence of structural abnormalities Could potentially stage at G3b A3 (red on the heat map)
bull Goal blood pressure
bull JNC 8 14090 NKF 13080
bull Additional lab needed for progression monitoring
bull Cbc renal panel phos Vit D iPTH uric acid urine micro (we already have the renal sono and urine proteincr ratio and lipid)
Selective renal angiography (left lower renal artery) after successful percutaneous balloon dilatation of the stenotic lesionFibromuscular dysplasia in an accessory renal artery causing renovascular hypertension
Secondary Hypertension
Images retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileRenal_FMD2jpg and httpcommonswikimediaorgwikiFileRenal_FMDjpgCreative Commons License associated httpcreativecommonsorglicensesby20deeden (both images)
CASE 2bull OS is a 64year old Hispanic female in for DM check She has had DM for 15+ years and is currently
taking metformin 1000mg bid Lisinopril 10mg a day atorvastatin 40mg a day Labs today showed the following
bull Hgba1c 86 cmp eGFR 50 lipid WNL proteincr ratio 650mg These results are similar to her last visit
bull Upon further hx-you find that she had a recent eye exam and has mild nonproliferaive retinopathy She does not have neuropathy or other ss
bull What further workup do you need
bull Renal sonogram urine micro iPTH vit D (25 OH) phos uric acid
bull Dx stage
bull G3a A3
bull What further treatment do you need
bull Improve glycemic control Increase Lisinopril to 20mg with a goal of 40mg Avoid NSAIDs or other nephrotoxic agents make sure meds are renally dosed monitor 3xyear nephro referral
MANAGEMENT OF CKD IN DIABETESeGFR Recommended
All patients
Yearly measurement of creatinine urinary albumin excretion potassium
45-60 Referral to a nephrologist if possibility for nondiabetickidney disease existsConsider dose adjustment of medicationsMonitor eGFR every 6 monthsMonitor electrolytes bicarbonate hemoglobin calcium phosphorus parathyroid hormone at least yearly
Assure vitamin D sufficiencyConsider bone density testingReferral for dietary counselling
American Diabetes Association Standards of Medical Care in Diabetes Microvascular complications and foot care Diabetes Care 2017 40 (Suppl 1) S88-S98
CASE 3
bull 19 year old African American woman presents to your clinic with complaints of fatigue joint pains a new rash on her face oral ulcer
bull On exam BP 15080 P 88 Afebrile 96 O2 sats on RAbull GEN No respiratory distress at restbull HEENT painless oral ulcer flat rash over malar eminences sparing the nasolabial fold pallor +bull Lungs CTAbull CVS S1S2 regularbull Abdomen soft NTbull Ext left elbow joint and bilateral wrist joints are swollen and tender
bull What would you orderbull CBC CMP ua urine microscopy (microalbumin or urine proteincr ratio) ANA esr RF anti-ccp uric acid TSH
CASE 3
bull Working dx fatigue oral ulcer joint pain
bull Basic Labs Na 135 K 55 Bicarb 18 BUN 50 Cr 35 eGFR 22 Ca 90 ANA + titer 1640
bull UA 3+ blood 3+ protein RBC casts +
bull Given these results what is the most likely diagnosis
bull What would you do
SYSTEMIC LUPUS ERYTHEMATOSUS (SLE)
bull SLE multisystemic disease Etiology unknown
bull Production of autoantibodies and immune complexes formation
bull There is renal involvement in the great majority of patients with SLE at some time of the evolution 66-90
SLE ndash LUPUS NEPHRITIS
bull Race SLE is more commonsevere in African americans than Caucasiansbull
bull Gender female-to-male ratio of 91
bull Age Most patients develop lupus nephritis early in their disease course SLE is more common among women in the third decade of life and lupus nephritis occurs in patients aged 20-40 years
bull Kidney Biopsy For staging lupus nephritis (Class 1-5)
CASE 5bull A 80 year old man who has not seen a PCP in many years
presents to your clinic for weakness for the past few months On further questioning he tells you that his bones also have been hurting lately and he has developed leg swelling in the past month or so
bull On exam bull BP 16090 P 88 Afebrilebull GEN Thin built manbull HEENT pallor presentbull Lungs clearbull CVS S1S2 regular no rub or gallopbull Abdomen soft NTbull Ext 2 + edema
CASE 5
bull Differentials
bull CHF MI Cancer arthritis
bull Labs
bull CBC CMP urine microscopy urine proteincr ratio ESR TSH EKG BNP pa and lat CXR
bull LABS Urine dipstick negative for protein or blood
bull Basic chem bull Na 136 (135-145) K 51 (35-55) Chloride 108 (96-106) Bicarb 25
Given this presentation and the labs (low anion gap and elevated calcium anemia kidney failure) what will you think of What will you order next
Serum and urine protein electrophoresis
Intratubular refractile casts with surrounding syncytial giant cell reaction with chronic tubulointerstitial nephritis and fibrosis characteristic of myeloma cast nephropathy
Kidney Biopsy
CASE STUDYbull A 35 year old African American woman was seen in the clinic for
chronic cough and dyspnea on exertion She gave history of vague symptoms of fatigue and weight loss of 20 Ibs over the last six months
bull List some differentialsbull TB sarcoid lupus thyroid problems PEbull What would you orderbull PPD cbc cmp UA TSH ANA pa and lat cxr
bull Her labs were significant for mildly elevated calcium level and a creatinine of 20 mgdL eGFR 37
bull She had 750 mg of proteinuriaday
bull PPD neg ANA neg TSH and other labs WNL
bull Assuming this is present more than 3 monthshelliphellipwhat is her ckd stage
bull G3b A3
bull What do we still need
CT scan of chest
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileAnterior_mediastinal_mass_thymomajpgCreative Commons License associated httpcreativecommonsorglicensesby20deeden
CXR ndash HILAR LYMPHADENOPATHY
WHATS NEEDED NEXT
bull Biopsy of hilar lymphadenopathy or renal biopsy
bull DX sarcoidosis
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileSarcoidosis_signs_and_symptomsjpgThis work is in the public domain in the United States because it is a work of the United States Federal Government under the terms of Title 17 Chapter 1 Section 105 of the US Code
NEWLY DX CKD
bull 1) urinalysis microscopy ultrasound proteincr ratio
bull If obstruction-treat
bull No obstruction
bull Hx critical (consider myeloma if high risk)
bull glomerular bleeding or albumin in urine
bull Yes workup for glomerular causes (ANArf hep B C upep spep ANCA complement C3 C4)
bull No sterile pyruria-consider interstitial nephritis
bull High risk renovascular disease Evaluate renovascular disease
Additional Online Resources for CKD LearningbullNational Kidney Foundation wwwkidneyorgbullUnited States Renal Data Service wwwusrdsorgbullCDCrsquos CKD Surveillance Project
httpnccdcdcgovckdbullNational Kidney Disease Education Program
(NKDEP) httpnkdepnihgov
BIBLIOGRAPHY
bull Afzali B amp Goldsmith D J (2016 June 29) Statins and chronic kidney disease (G C Curhan amp A M Sheridan Eds) Retrieved 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsstatins-and-chronic-kidney-disease
bull American Diabetes Association Standards of Medical Care in Diabetes (2017) Microvascular complications and foot care Diabetes Care 2017 (40) S88-S98
bull American Diabetes Association Standards of Medical Care in Diabetes (2017) Microvascular complications and foot care Diabetes Care 40 (suppl 1) S88-S98
bull Berns J S (2017 Mar 22) Treatment of anemia in nondialysis chronic kidney disease (T A Golper amp A M Sheridan Eds) Retrieved from UpToDate httpswww-uptodate-comproxywichitaeducontentstreatment-of-anemia-in-nondialysis-chronic-kidney-disease
bull Chan M Dall A T Fletcher K E Lu N amp Trivedi H (2007) Outcomes in patients with chronic kidney disease referred late to nephrologists a meta-analysis American Journal of Medicine 120(12) 1063-1070
bull Coresh J Selvin E amp Stevens L A (2007) Prevalence of chronic kidny disease in the United States JAMA 298(17) doi101001jama298172038
bull de Brito-Ashurst I Varagunam M Raftery M amp Yagoob M (2009) Bicarbonate supplementation slows progression of CKD and improves nutritional status Journal of American Society of Nephrology (20) 2075-2084
BIBLIOGRAPHY
bull Duncan L Heathcoat J Djurdjev O amp Levin A (2001) Screening for renal disease using serum creatinine who are we missing Nephrology Dialysis and Transplant 16(5) 1042-1046
bull Dunkler D Gao P Lee S F Heinz G Clase C M Tobe S Oberbauer R (2015 August 7) Risk prediction for early CKD in type 2 diabetes Retrieved from Clinical Journal of the American Society of Nephrology httpcjasnasnjournalsorgcontent1081371fullsid=61422554-a5f1-41ac-b696-dcd3b12bd268
bull Fatehi P amp Chi-yuan H (September 15 2016) Diagnostic approach to the patient with newly identified chronic kidney disease (G C Curhan amp A M Sheridan Eds) Retrieved May 7 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsdiagnostic-approach-to-the-patient-with-newly-identified-chronic-kidney-disease
bull Fink J e (2009) Chronic Kidney Disease as an Under-Recognized Threat to Patient Safety American journal of kidney diseases the official journal of the National Kidney Foundation 53(4) 681-688
bull Gaffo A L amp Saag K G (2008 Nov) Management of hyperuricemia and gout in CKD doihttpdxdoiorg101053jajkd200807035
bull Hebert L A amp Parikh S V (2014 June 18) Differential diagnosis and evaluation of glomerular disease (R J Glassock amp A Q Lam Eds) Retrieved May 7 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsdifferential-diagnosis-and-evaluation-of-glomerular-disease
bull Inker L Perrone R D Sterns R H amp Forman J P (2017 March 7) Assessment of kidney function Retrieved from UpToDate httpswww-uptodate-comproxywichitaeducontentsassessment-of-kidney-functionsource=search_resultampsearch=creatinineampselectedTitle=1~150
BIBLIOGRAPHY
bull James P A Ortiz E amp Et Al (2014) Evidence based guideline for the management of high blood pressure in adults (JNC) JAMA 311(5) 507-520
bull Kidney Disease Improving Global Outcomes (KDIGO) CKD Work Group (2013 January) KDIGO 2012 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease Retrieved from Kidney International Supplement httpwwwkidney-internationalorg
bull Kunz R Friedrich C Wolbers M amp Mann J F (2008) Meta-analysis effect of monotherapy and combination therapy with inhibitors of the renin angiotensin system on proteinuria in renal disease Annals of Internal Medicine 148(1) 30-48
bull Levey A Stevens L A Schmid C H Castro A F Feldman H I Kusek J W Coresh J (2009) A new equation to estimate glomerular filtration rate Annals of Internal Medicine 150(9) 604-612
bull Levin A Bakris G L Molitch M Smulders M M Williams L A amp Andress D L (2007 Jan) Prevalence of abnormal serum vitamin D PTH calcium and phosphorus in patients with chronic kidney disease results of the study to evaluate early kidney disease Kidney International 71(1) 31-38 Retrieved from PubMED
bull Mahajan A Simoni J Sheather S Broglio K Rajab M amp Wesson D (2010) Daily oral sodium bicarbonate preserves glomerular filtration rate by slowing its decline in early hypertensive nephropathy Kidney International (78_ 303-309
bull Mann J Schmieder R E amp McQueen M (2008) Renal outcomes with telmisartan ramipril or both in people at high vascular risk (the ONTARGET study) a multicentre randomised doubleblind ocntrolled trial Lancet 372(9638) 547-533
BIBLIOGRAPHY
bull Matovinović M S (2009) Pathophysiology and classification of kidney disease Retrieved from The Journal of the International Federation of Clinical Chemistry and Laboratory Medicine httpwwwifccorgifccfilesdocs20010902pdf
bull Moe S Drueke T Lameire N amp Eknoyan G (2007 Jan) Chronic kidney disease-mineral-bone disorder a new paradigmdoi101053jackd200610005
bull Murtagh F E Marsh J E Donohoe P Ekbal N J Sheerin N S amp Harris F E (2007 July) Dialysis or not A comparative survival study of patients over 75 years with chronic kidney disease stage 5 Retrieved from Nephrology Dialysis and Transplant 22(7) httpswwwncbinlmnihgovpubmed17412702
bull National Kidney Foundation (2002) KDOQI clinical practice guidelines for chronic kidney disease evaluation classification andstratification American Journal of Kidney Disease S1-S266
bull National Kidney Foundation (2014 November 5) Fact Sheets Retrieved from httpwwwkidneyorgnewsnewsroomfactsheetsFastFacts
bull Pal S (2012 June 2) Trends in chronic kidney disease Retrieved from US Pharmacist (37)6 httpswwwuspharmacistcomarticletrends-in-chronic-kidney-disease
bull Qunibi W amp Henrich W L (2017 Jan 19) Overview of chronic kidney disease-mineral and bone disorder (J Berns amp A M Sheridan Eds) Retrieved from UpToDate httpswww-uptodate-comoverview-of-chronic-kidney-disease-mineral-and-bone-disorder-ckd-mbd
bull Rosenberg M (2016 Feb 24) Overview of the management of chronic kidney disease in adults (G C Curhan amp A M Sheridan Eds) Retrieved from UpToDate UpToDate httpswww-uptodate-comproxywichitaeducontentsoverview-of-the-management-of-chronic-kidney-disease-in-adults
BIBLIOGRAPHY
bull Szczech L Stewart R C Hsu-Lin S DeLosky R J Astor B C Fox C H Vassalotti J A (2014) Primary care detection of chronic kidney disease in adults with type 2 diabetes The ADD-CKD Study (Awareness Detection and Drug Therapy in type 2 diabetes and chronic kidney disease PLOS doihttpsdoiorg101371journalpone0110535
bull USRDS (2016) Annual data report 2016 Epidemiology of kidney disease in the United States Retrieved from United States Renal Data System httpswwwusrdsorgadraspx
bull Vasudev B amp Vasudev M (2012) A model curriculum for residents rotating in nephrology MedEDPORTAL doihttpdoiorg1015766mep_2374-82658288
bull Wei L MacDonald T M Jennings C Sheng X amp Flynn R W (2013) Estimated GFR reporting is associated with decreased nonsteroidal anti-inflammatory drug prescribing and increased renal function Kidney International (84)1 174-178
chronic kidney disease in primary care
CKD as a Public Health Issue
Slide Number 3
Costs of CKD in 2013 dollarsUSRDS report
Steps to CKD Patient Care
Renal anatomy and physiology
Definition of Chronic Kidney Disease
CKD Risk Factors
Gaps in CKD Diagnosis
Slide Number 10
Steps to CKD Patient Care
creatinine
Glomerular filtration rate
Slide Number 14
Slide Number 15
Use These Equations Cautiously if at all in hellip
lab albumin creatinine ratio
The New CKD Categories
Steps to CKD Patient Care
Slide Number 20
Kidney Involvement in Systemic Diseases
Slide Number 22
Slide Number 23
DysmorphicRenal Hematuria
Slide Number 25
If you have albuminuria or hematuria-order the following labs
Prevalence of Abnormalities of Mineral Metabolism PTH in CKD
Managing CKD-MBD complications
CKD-MBD Testing
Anemia Becomes More Common as Kidney Function Declines
Detect and Manage CKD Complications
Complications-metabolic acidosis
Complications-vascular calcification
Hyperkalemia management
Hyperuricemia levels amp CKD
CKD monitoring levels 345
Slide Number 59
When to Refer to a Nephrologist
When to Refer
Steps to CKD Patient Care
Kidney transplantation
Starting Dialysis in the ElderlyhellipOr Not
Ckd management
Case 1
Slide Number 67
Lab results
Slide Number 69
Hypertensive nephropathy with proteinuria
Slide Number 71
Case 2
Slide Number 73
Management of CKD in Diabetes
Case 3
Case 3
Systemic Lupus Erythematosus (SLE)
SLE ndash Lupus Nephritis
Case 5
Case 5
Slide Number 81
Slide Number 82
Case study
Slide Number 84
CXR ndash Hilar Lymphadenopathy
Whats needed next
Slide Number 87
newly dx ckd
Slide Number 89
Bibliography
bibliography
bibliography
bibliography
bibliography
Stage 12
Stage 3
Stage 4
Stage 5
Hb le10 gdL
52
56
11
272
Hb gt10-le12 gdL
216
359
426
483
Hb le12 gdL
267
416
536
755
Stage 12
Stage 3
Stage 4
Stage 5
or lt 15 mLmin173m2
(Levey et al 2009)
True GFR could be gt 70 mLmin173m2
The ldquoerdquo in eGFR Stands for ldquoEstimatedrdquohellip
USE THESE EQUATIONS CAUTIOUSLY IF AT ALL IN hellip
bull Patients who haveare
bull Poor nutritionloss of muscle mass
bull Amputation
bull Chronic illness
bull Not African American or Caucasian
bull Changing serum creatinine
bull Obese
bull Very elderly young
(National Kidney Foundation 2014)
LAB ALBUMIN CREATININE RATIO
bull Urinary albumin-to-creatinine ratio (ACR) is calculated by dividing albumin concentration in milligrams by creatinine concentration in grams
bull Creatinine assists in adjusting albumin levels for varying urine concentrations which allows for more accurate results versus albumin alone
bull Spot urine albumin-to-creatinine ratio for quantification of proteinuria
bull New guidelines classify albuminuria as mild moderately or severely increased
bull First morning void preferable
bull 24hr urine test rarely necessary
THE NEW CKD CATEGORIES
STEPS TO CKD PATIENT CARE
1 CKD definition and risks2 Assess GFR albuminuria3 Determine etiology- what is going on here4 Slow progression5 Assess for associated complications6 Discuss dialysistransplantation
(Pal 2012)
KIDNEY INVOLVEMENT IN SYSTEMIC DISEASES
Hypertension
DiabetesAmyloidosis
Sickle cell diseases
Immune complex GN
Illicit drugs ndash cocaine heroin
Cholesterol emboli
HIV
Allergic reactions- drugsinterstitial nephritis
Hemolytic Uremic syndrome
Lupus
Systemic vasculitis
Liver FailureCongestive heart Failure
Image retrieved on 05 October 2010 from httpenwikipediaorgwikiFileGray1129pngThis image is under the public domain and not copyrightable in the US as per Bridgeman Art Library v Corel Corp
(Vasudev amp Vasudev 2012)
New CKD
Obtain ultrasound UA
microscopy albumincr ratio
Ultrasound shows
obstruction
bull Yes Relieve obstruction
bull No Is there albuminuria or glomerular bleeding (eval for glomerulo-nephritis
Fatehi amp Chi-yuan 2016
If red cells have their typical shape and color this indicates extra glomerular hematuria
Examples kidney stone disease UTI cystitis bleeding from collecting duct ureters bladder or urethra
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileReactive_lymphJPGCreative Commons License associated httpcreativecommonsorglicensesby-sa30deeden
(Vasudev amp Vasudev 2012)
DYSMORPHICRENAL HEMATURIA
bull This hematuria is characterized by bull a great variation in the size of the cells and by a high
percentage of dysmorphocytosiscasts (gt20)
bull Hematuria is usually related to glomerular bleeding bull It is typically accompanied by variable levels of albumuniuria
(Vasudev amp Vasudev 2012)
Urinary Cast Formation
Urine Microscopy can be helpful in work up of chronic kidney disease
In GNrsquos the red blood cells leak from the glomerulus into the tubules As they traverse through the tubules they can form cylindrical casts calledRBC casts
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileRedbloodcellsjpgThis image is a work of the National Institutes of Health part of the United States Department of Health and Human Services As a work of the US federal government the image is in the public domain
(Vasudev amp Vasudev 2012)
IF YOU HAVE ALBUMINURIA OR HEMATURIA-ORDER THE FOLLOWING LABS
Tests of autoimmunity Hepatitis serologies gt40 years- paraproteinassessment
ANA Hepatitis B serology (HBsAG)
Serum protein electrophoresis (SPEP)
RFanti-ccp Hepatitis C serology(HCV antibody)
Urine protein electrophoresis (UPEP)
Complement C3 C4
ANCANational Kidney Disease Education Program 2014 NIH
UPTODATE LAB RECOMENDATIONS
bull Lab to order cbc cmp urine albumincr ratio urine microscopy
bull Nephrotic pattern (protein gt35gday) ANA anti DS DNA C3 and C4 antibodies HIV HBV HCV serumurine immunofixation (amyloidosis) free light chain analysis (light chain deposition disease)
bull Nephritic pattern (red cells white cells casts variable protein) C3 C4 ANA dsDNA antineutrophil cytoplasmic antibody (ANCA) titers a streptozyme test HBV and HCV serologies HIV and in some cases blood cultures anti-glomerular basement membrane (GBM) antibodies and cryoglobulins
bull Renal biopsy(Hebert amp Parikh 2014)
EVALUATION OF NEW CKDNO OBSTRUCTION
NO EVIDENCE OF GLOMERULAR BLEEDING
High risk for multmyeloma (gt40
no nsaids no contrast
SPEP UPEP with immunofixation serum free light
chains
Evaluation depends on UA
Sterile pyuria
Eval for interstitial nephritis
Normal urinalysis
High risk for renovascular
disease
Eval for renovascular
disease
Follow serum creatinine-does it
remain stable(Fatehi amp Chi-yuan 2016)
POSSIBLE INVESTIGATIONShellip
Acute interstitial nephritisbull Drugs are the most common cause of AIN
DIABETIC NEPHROPATHY 1 CAUSE OF CKDbull Clinical syndromebull Albuminuria gt30 mg 24 hrsbull Proteinuria gt500 mg24 hrsbull Hypertension developsbull Progressive increase in proteinuriabull Progressive decline in glomerular filtration rate
bull Chronic kidney disease should be attributed to diabetic nephropathies in most patients with diabetes if albuminuria and diabetic retinopathy are both present other causes of CKD should be entertained if diabetic retinopathy is absent (KDIGO 2007)
DIABETIC NEPHROPATHY MORTALITY
bull After 40 yrs of DM
bull 10 alive if proteinuria is present
bull 70 alive if proteinuria is absent
bull Heart Disease is 15 times higher risk in those with proteinuria
bull Proteinuria = death in this population
Dunkler et al 2015
GOALS OF CARE IN CKD GLUCOSE CONTROL
bull Target HbA1c ~70 (lt695 greatest chance of reducing albuminuria)bull Can be extended above 70 with comorbidities or limited life expectancy and
risk of hypoglycemiabull Risk of hypoglycemia increases as kidney function becomes impairedbull Declining kidney function may necessitate changes to diabetes medications and
bull Just having HTN can cause proteinuriabull Usually 1-2 gms of protein a daybull Treat them like a diabetic with ACEI or ARBS and tight blood
pressure controlbull JNC-8 goal lt14090 for ptrsquos with CKDbull National kidney foundation lt14090 if ckd and no proteinuria
lt13080 if proteinuria present
(James Ortiz amp Et Al 2014)
TREATING HYPERTENSIONPROTEINURIA ACEI ORARBbull Riskbenefit should be carefully assessed in the elderly and medically fragilebull Check labs after initiation
bull If less than 30 SCr increase continue and monitorbull If more than 30 SCr increase stop ACEi and evaluate for renal artery stenosis
bull Continue until contraindication arises no absolute eGFR cutoffbull Better proteinuria suppression with low Na diet and diureticsbull Avoid volume depletionbull Avoid ACEi and ARB in combination12
bull Risk of adverse events (impaired kidney function hyperkalemia)
(Kunz Friedrich Wolbers amp Mann 2008)(Mann Schmieder amp McQueen 2008)
bull In adults gt50 yrs statin when eGFR ge 60 mlmin173m2 statin or statinezetimibe combination when eGFR lt 60 mlmin173m2
bull In adults lt 50 yrs statin if history of known CAD MI DM strokebull Aspirin is indicated for secondary but not primary prevention
Kidney Disease Improving Global Outcomes (KDIGO) CKD Work Group Kidney Int Suppls 201331-150
STATINS-RENOPROTECTIVECONTROVERSY
bull HMG-CoA reductase inhibitors (statins) in high doses can cause proteinuria
bull Possibly associated with less inflammation endothelial dysfunction and scarring in the kidney because they also block inflammatory cytokines
bull Use statins for CV disease not to treat proteinuria
(Afzali and Goldsmith 2016)
MEDICINE CAUTION
bull Hold metformin when gfr lt35 mlmin
bull GFR lt50 mlmin should alert to check all doses of meds
bull No bisphosphanates lt35 mlmin
bull No NSAIDScox 2 inhibitors lt60 mlmin
bull Atenolol ndashrenal excretion
bull BACTRIM A lot of AKI
MEDICINE CAUTION
bull Lovenox-use subcut heparinbull Apixibanbull Dabigatranbull Rivaroxibanbull Lithiumbull GABAPENTIN (ckd 4 max 300mg qd ckd 5 max 300mg qod)
STEPS TO CKD PATIENT CARE
1 CKD definition and risks2 Assess GFR albuminuria3 Determine etiology4 Assess for evidence of progression5 Assess for associated complications6 Discuss dialysistransplantation
CKD-CVD-DIABETES LINK CKD IS A DISEASE MULTIPLIER
National kidney foundation 2014
KDIGO 2017
CKD-MINERAL BONE DISORDERS
bull As kidneys fail they
bull Stop activating calcitriol (the active form of Vit D)mdashcausing calcium imbalance
bull Do not remove phosphorus from bloodmdashleading to phosphorus retention
bull The extra phosphorus pulls calcium out of bones causing them to weaken
bull High phosphorus stimulates PTH release
bull These changes (plus others) cause the start of secondary hyperparathyroidism
bull Labs
bull eGFR
bull Calcium
bull Phos
bull Vit D
bull iPTH
(Qunibi amp Henrich 2017)
PREVALENCE OF ABNORMALITIES OF MINERAL METABOLISM PTH IN CKD
bull Progression of disease ndash declining eGFR increasing proteinuria
bull Degree of proteinuria nephrotic syndrome gt 05-10 gd on ACEi or ARB therapy
bull Etiology of CKD not certain
bull Need help with disease management
bull Indications for kidney biopsy
Rosenberg 2016
WHEN TO REFER
STEPS TO CKD PATIENT CARE
1 CKD definition and risks2 Assess GFR albuminuria3 Determine etiology4 Assess for evidence of progression5 Assess for associated complications6 Discuss dialysistransplantation
KIDNEY TRANSPLANTATION
bull Treatment of choice for ESRDbull Improves quality of lifebull Waiting list time varies-3-5 yearsbull 3 year survival rate after transplantation is 83-94bull Increased risk of cancer
STARTING DIALYSIS IN THE ELDERLYhellipOR NOT
bull Among patients gt 75 yrs with stage 5 CKD who chose to NOT start dialysisbull Overall more likely to die over next 1-2 years bull But if they had ischemic heart disease or other significant comorbidity NO
DIFFERENCE in survival
bull Active disease management and supportive care may be appropriate without starting dialysis in the ill elderly
bull Palliative care does not mean ldquono carerdquo
bull Must have end-of-life discussions
(Murtagh et al 2007)
CKD MANAGEMENTbull Diagnose cause and treat underlying conditionbull Stage per guidelinesbull Slow progression of kidney disease (ACE inhibitors)bull Monitor for complicationsmdashvolume overload hyperkalemia metabolic acidosis
hyperphosphatemia anorexia fatigue htn bone diseasebull Labs cmp cbc phos Vit D 25OH iPTH urine microscopy uric acid urine
proteincr ratio-frequency based off heat map Get sono at least oncebull Vaccinate influenza hep B pneumococcalbull Eval ASCVD risk-likely needs statinbull Possible dexa (donrsquot give bisphosphonates if GFRlt35 let specialist manage)bull Refer to nephrology when eGFR is lt30 (sometimes if higher risk-refer earlier)
CASE 1
bull 55 year old man with past medical history of headaches presents to your office for his first time visit to a PCP in over 30 years
bull He has no past history of being admitted to the hospital and he does not take any OTC medsNSAIDsherbal meds He has no history of ETOH abuse smoking or drug use
bull Vitals BP 180100 mmHg pulse 80 R 18
bull Exam No JVD S1S2 regular PMI shifted to the left no gallop no abdominal bruit pulses bilaterally equal and regular no leg edema
bull What would you order
bull EKG cbc cmp ua urine proteincr ratio lipid
LAB RESULTS
bull Labs reveal a creatinine of 22 mgdL eGFR 33 Urine shows no blood or casts Urineprotein ratio shows 1 gm protein24 hrs EKG shows LVH
bull Next step in workupbull Renal ultrasound 1st then SPEP UPEP with immunofixation serum free light chains
bull Additional labs neg Renal ultrasound shows that both kidneys are slightly reduced in size and are mildly echogenic with no mass or hydronephrosis
bull What is your diagnosis
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileMain_complications_of_persistent_high_blood_pressurepngCreative Commons License associated httpcreativecommonsorglicensesby-sa30
bull 3 months Howevermdashwe have evidence of structural abnormalities Could potentially stage at G3b A3 (red on the heat map)
bull Goal blood pressure
bull JNC 8 14090 NKF 13080
bull Additional lab needed for progression monitoring
bull Cbc renal panel phos Vit D iPTH uric acid urine micro (we already have the renal sono and urine proteincr ratio and lipid)
Selective renal angiography (left lower renal artery) after successful percutaneous balloon dilatation of the stenotic lesionFibromuscular dysplasia in an accessory renal artery causing renovascular hypertension
Secondary Hypertension
Images retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileRenal_FMD2jpg and httpcommonswikimediaorgwikiFileRenal_FMDjpgCreative Commons License associated httpcreativecommonsorglicensesby20deeden (both images)
CASE 2bull OS is a 64year old Hispanic female in for DM check She has had DM for 15+ years and is currently
taking metformin 1000mg bid Lisinopril 10mg a day atorvastatin 40mg a day Labs today showed the following
bull Hgba1c 86 cmp eGFR 50 lipid WNL proteincr ratio 650mg These results are similar to her last visit
bull Upon further hx-you find that she had a recent eye exam and has mild nonproliferaive retinopathy She does not have neuropathy or other ss
bull What further workup do you need
bull Renal sonogram urine micro iPTH vit D (25 OH) phos uric acid
bull Dx stage
bull G3a A3
bull What further treatment do you need
bull Improve glycemic control Increase Lisinopril to 20mg with a goal of 40mg Avoid NSAIDs or other nephrotoxic agents make sure meds are renally dosed monitor 3xyear nephro referral
MANAGEMENT OF CKD IN DIABETESeGFR Recommended
All patients
Yearly measurement of creatinine urinary albumin excretion potassium
45-60 Referral to a nephrologist if possibility for nondiabetickidney disease existsConsider dose adjustment of medicationsMonitor eGFR every 6 monthsMonitor electrolytes bicarbonate hemoglobin calcium phosphorus parathyroid hormone at least yearly
Assure vitamin D sufficiencyConsider bone density testingReferral for dietary counselling
American Diabetes Association Standards of Medical Care in Diabetes Microvascular complications and foot care Diabetes Care 2017 40 (Suppl 1) S88-S98
CASE 3
bull 19 year old African American woman presents to your clinic with complaints of fatigue joint pains a new rash on her face oral ulcer
bull On exam BP 15080 P 88 Afebrile 96 O2 sats on RAbull GEN No respiratory distress at restbull HEENT painless oral ulcer flat rash over malar eminences sparing the nasolabial fold pallor +bull Lungs CTAbull CVS S1S2 regularbull Abdomen soft NTbull Ext left elbow joint and bilateral wrist joints are swollen and tender
bull What would you orderbull CBC CMP ua urine microscopy (microalbumin or urine proteincr ratio) ANA esr RF anti-ccp uric acid TSH
CASE 3
bull Working dx fatigue oral ulcer joint pain
bull Basic Labs Na 135 K 55 Bicarb 18 BUN 50 Cr 35 eGFR 22 Ca 90 ANA + titer 1640
bull UA 3+ blood 3+ protein RBC casts +
bull Given these results what is the most likely diagnosis
bull What would you do
SYSTEMIC LUPUS ERYTHEMATOSUS (SLE)
bull SLE multisystemic disease Etiology unknown
bull Production of autoantibodies and immune complexes formation
bull There is renal involvement in the great majority of patients with SLE at some time of the evolution 66-90
SLE ndash LUPUS NEPHRITIS
bull Race SLE is more commonsevere in African americans than Caucasiansbull
bull Gender female-to-male ratio of 91
bull Age Most patients develop lupus nephritis early in their disease course SLE is more common among women in the third decade of life and lupus nephritis occurs in patients aged 20-40 years
bull Kidney Biopsy For staging lupus nephritis (Class 1-5)
CASE 5bull A 80 year old man who has not seen a PCP in many years
presents to your clinic for weakness for the past few months On further questioning he tells you that his bones also have been hurting lately and he has developed leg swelling in the past month or so
bull On exam bull BP 16090 P 88 Afebrilebull GEN Thin built manbull HEENT pallor presentbull Lungs clearbull CVS S1S2 regular no rub or gallopbull Abdomen soft NTbull Ext 2 + edema
CASE 5
bull Differentials
bull CHF MI Cancer arthritis
bull Labs
bull CBC CMP urine microscopy urine proteincr ratio ESR TSH EKG BNP pa and lat CXR
bull LABS Urine dipstick negative for protein or blood
bull Basic chem bull Na 136 (135-145) K 51 (35-55) Chloride 108 (96-106) Bicarb 25
Given this presentation and the labs (low anion gap and elevated calcium anemia kidney failure) what will you think of What will you order next
Serum and urine protein electrophoresis
Intratubular refractile casts with surrounding syncytial giant cell reaction with chronic tubulointerstitial nephritis and fibrosis characteristic of myeloma cast nephropathy
Kidney Biopsy
CASE STUDYbull A 35 year old African American woman was seen in the clinic for
chronic cough and dyspnea on exertion She gave history of vague symptoms of fatigue and weight loss of 20 Ibs over the last six months
bull List some differentialsbull TB sarcoid lupus thyroid problems PEbull What would you orderbull PPD cbc cmp UA TSH ANA pa and lat cxr
bull Her labs were significant for mildly elevated calcium level and a creatinine of 20 mgdL eGFR 37
bull She had 750 mg of proteinuriaday
bull PPD neg ANA neg TSH and other labs WNL
bull Assuming this is present more than 3 monthshelliphellipwhat is her ckd stage
bull G3b A3
bull What do we still need
CT scan of chest
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileAnterior_mediastinal_mass_thymomajpgCreative Commons License associated httpcreativecommonsorglicensesby20deeden
CXR ndash HILAR LYMPHADENOPATHY
WHATS NEEDED NEXT
bull Biopsy of hilar lymphadenopathy or renal biopsy
bull DX sarcoidosis
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileSarcoidosis_signs_and_symptomsjpgThis work is in the public domain in the United States because it is a work of the United States Federal Government under the terms of Title 17 Chapter 1 Section 105 of the US Code
NEWLY DX CKD
bull 1) urinalysis microscopy ultrasound proteincr ratio
bull If obstruction-treat
bull No obstruction
bull Hx critical (consider myeloma if high risk)
bull glomerular bleeding or albumin in urine
bull Yes workup for glomerular causes (ANArf hep B C upep spep ANCA complement C3 C4)
bull No sterile pyruria-consider interstitial nephritis
bull High risk renovascular disease Evaluate renovascular disease
Additional Online Resources for CKD LearningbullNational Kidney Foundation wwwkidneyorgbullUnited States Renal Data Service wwwusrdsorgbullCDCrsquos CKD Surveillance Project
httpnccdcdcgovckdbullNational Kidney Disease Education Program
(NKDEP) httpnkdepnihgov
BIBLIOGRAPHY
bull Afzali B amp Goldsmith D J (2016 June 29) Statins and chronic kidney disease (G C Curhan amp A M Sheridan Eds) Retrieved 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsstatins-and-chronic-kidney-disease
bull American Diabetes Association Standards of Medical Care in Diabetes (2017) Microvascular complications and foot care Diabetes Care 2017 (40) S88-S98
bull American Diabetes Association Standards of Medical Care in Diabetes (2017) Microvascular complications and foot care Diabetes Care 40 (suppl 1) S88-S98
bull Berns J S (2017 Mar 22) Treatment of anemia in nondialysis chronic kidney disease (T A Golper amp A M Sheridan Eds) Retrieved from UpToDate httpswww-uptodate-comproxywichitaeducontentstreatment-of-anemia-in-nondialysis-chronic-kidney-disease
bull Chan M Dall A T Fletcher K E Lu N amp Trivedi H (2007) Outcomes in patients with chronic kidney disease referred late to nephrologists a meta-analysis American Journal of Medicine 120(12) 1063-1070
bull Coresh J Selvin E amp Stevens L A (2007) Prevalence of chronic kidny disease in the United States JAMA 298(17) doi101001jama298172038
bull de Brito-Ashurst I Varagunam M Raftery M amp Yagoob M (2009) Bicarbonate supplementation slows progression of CKD and improves nutritional status Journal of American Society of Nephrology (20) 2075-2084
BIBLIOGRAPHY
bull Duncan L Heathcoat J Djurdjev O amp Levin A (2001) Screening for renal disease using serum creatinine who are we missing Nephrology Dialysis and Transplant 16(5) 1042-1046
bull Dunkler D Gao P Lee S F Heinz G Clase C M Tobe S Oberbauer R (2015 August 7) Risk prediction for early CKD in type 2 diabetes Retrieved from Clinical Journal of the American Society of Nephrology httpcjasnasnjournalsorgcontent1081371fullsid=61422554-a5f1-41ac-b696-dcd3b12bd268
bull Fatehi P amp Chi-yuan H (September 15 2016) Diagnostic approach to the patient with newly identified chronic kidney disease (G C Curhan amp A M Sheridan Eds) Retrieved May 7 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsdiagnostic-approach-to-the-patient-with-newly-identified-chronic-kidney-disease
bull Fink J e (2009) Chronic Kidney Disease as an Under-Recognized Threat to Patient Safety American journal of kidney diseases the official journal of the National Kidney Foundation 53(4) 681-688
bull Gaffo A L amp Saag K G (2008 Nov) Management of hyperuricemia and gout in CKD doihttpdxdoiorg101053jajkd200807035
bull Hebert L A amp Parikh S V (2014 June 18) Differential diagnosis and evaluation of glomerular disease (R J Glassock amp A Q Lam Eds) Retrieved May 7 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsdifferential-diagnosis-and-evaluation-of-glomerular-disease
bull Inker L Perrone R D Sterns R H amp Forman J P (2017 March 7) Assessment of kidney function Retrieved from UpToDate httpswww-uptodate-comproxywichitaeducontentsassessment-of-kidney-functionsource=search_resultampsearch=creatinineampselectedTitle=1~150
BIBLIOGRAPHY
bull James P A Ortiz E amp Et Al (2014) Evidence based guideline for the management of high blood pressure in adults (JNC) JAMA 311(5) 507-520
bull Kidney Disease Improving Global Outcomes (KDIGO) CKD Work Group (2013 January) KDIGO 2012 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease Retrieved from Kidney International Supplement httpwwwkidney-internationalorg
bull Kunz R Friedrich C Wolbers M amp Mann J F (2008) Meta-analysis effect of monotherapy and combination therapy with inhibitors of the renin angiotensin system on proteinuria in renal disease Annals of Internal Medicine 148(1) 30-48
bull Levey A Stevens L A Schmid C H Castro A F Feldman H I Kusek J W Coresh J (2009) A new equation to estimate glomerular filtration rate Annals of Internal Medicine 150(9) 604-612
bull Levin A Bakris G L Molitch M Smulders M M Williams L A amp Andress D L (2007 Jan) Prevalence of abnormal serum vitamin D PTH calcium and phosphorus in patients with chronic kidney disease results of the study to evaluate early kidney disease Kidney International 71(1) 31-38 Retrieved from PubMED
bull Mahajan A Simoni J Sheather S Broglio K Rajab M amp Wesson D (2010) Daily oral sodium bicarbonate preserves glomerular filtration rate by slowing its decline in early hypertensive nephropathy Kidney International (78_ 303-309
bull Mann J Schmieder R E amp McQueen M (2008) Renal outcomes with telmisartan ramipril or both in people at high vascular risk (the ONTARGET study) a multicentre randomised doubleblind ocntrolled trial Lancet 372(9638) 547-533
BIBLIOGRAPHY
bull Matovinović M S (2009) Pathophysiology and classification of kidney disease Retrieved from The Journal of the International Federation of Clinical Chemistry and Laboratory Medicine httpwwwifccorgifccfilesdocs20010902pdf
bull Moe S Drueke T Lameire N amp Eknoyan G (2007 Jan) Chronic kidney disease-mineral-bone disorder a new paradigmdoi101053jackd200610005
bull Murtagh F E Marsh J E Donohoe P Ekbal N J Sheerin N S amp Harris F E (2007 July) Dialysis or not A comparative survival study of patients over 75 years with chronic kidney disease stage 5 Retrieved from Nephrology Dialysis and Transplant 22(7) httpswwwncbinlmnihgovpubmed17412702
bull National Kidney Foundation (2002) KDOQI clinical practice guidelines for chronic kidney disease evaluation classification andstratification American Journal of Kidney Disease S1-S266
bull National Kidney Foundation (2014 November 5) Fact Sheets Retrieved from httpwwwkidneyorgnewsnewsroomfactsheetsFastFacts
bull Pal S (2012 June 2) Trends in chronic kidney disease Retrieved from US Pharmacist (37)6 httpswwwuspharmacistcomarticletrends-in-chronic-kidney-disease
bull Qunibi W amp Henrich W L (2017 Jan 19) Overview of chronic kidney disease-mineral and bone disorder (J Berns amp A M Sheridan Eds) Retrieved from UpToDate httpswww-uptodate-comoverview-of-chronic-kidney-disease-mineral-and-bone-disorder-ckd-mbd
bull Rosenberg M (2016 Feb 24) Overview of the management of chronic kidney disease in adults (G C Curhan amp A M Sheridan Eds) Retrieved from UpToDate UpToDate httpswww-uptodate-comproxywichitaeducontentsoverview-of-the-management-of-chronic-kidney-disease-in-adults
BIBLIOGRAPHY
bull Szczech L Stewart R C Hsu-Lin S DeLosky R J Astor B C Fox C H Vassalotti J A (2014) Primary care detection of chronic kidney disease in adults with type 2 diabetes The ADD-CKD Study (Awareness Detection and Drug Therapy in type 2 diabetes and chronic kidney disease PLOS doihttpsdoiorg101371journalpone0110535
bull USRDS (2016) Annual data report 2016 Epidemiology of kidney disease in the United States Retrieved from United States Renal Data System httpswwwusrdsorgadraspx
bull Vasudev B amp Vasudev M (2012) A model curriculum for residents rotating in nephrology MedEDPORTAL doihttpdoiorg1015766mep_2374-82658288
bull Wei L MacDonald T M Jennings C Sheng X amp Flynn R W (2013) Estimated GFR reporting is associated with decreased nonsteroidal anti-inflammatory drug prescribing and increased renal function Kidney International (84)1 174-178
chronic kidney disease in primary care
CKD as a Public Health Issue
Slide Number 3
Costs of CKD in 2013 dollarsUSRDS report
Steps to CKD Patient Care
Renal anatomy and physiology
Definition of Chronic Kidney Disease
CKD Risk Factors
Gaps in CKD Diagnosis
Slide Number 10
Steps to CKD Patient Care
creatinine
Glomerular filtration rate
Slide Number 14
Slide Number 15
Use These Equations Cautiously if at all in hellip
lab albumin creatinine ratio
The New CKD Categories
Steps to CKD Patient Care
Slide Number 20
Kidney Involvement in Systemic Diseases
Slide Number 22
Slide Number 23
DysmorphicRenal Hematuria
Slide Number 25
If you have albuminuria or hematuria-order the following labs
Prevalence of Abnormalities of Mineral Metabolism PTH in CKD
Managing CKD-MBD complications
CKD-MBD Testing
Anemia Becomes More Common as Kidney Function Declines
Detect and Manage CKD Complications
Complications-metabolic acidosis
Complications-vascular calcification
Hyperkalemia management
Hyperuricemia levels amp CKD
CKD monitoring levels 345
Slide Number 59
When to Refer to a Nephrologist
When to Refer
Steps to CKD Patient Care
Kidney transplantation
Starting Dialysis in the ElderlyhellipOr Not
Ckd management
Case 1
Slide Number 67
Lab results
Slide Number 69
Hypertensive nephropathy with proteinuria
Slide Number 71
Case 2
Slide Number 73
Management of CKD in Diabetes
Case 3
Case 3
Systemic Lupus Erythematosus (SLE)
SLE ndash Lupus Nephritis
Case 5
Case 5
Slide Number 81
Slide Number 82
Case study
Slide Number 84
CXR ndash Hilar Lymphadenopathy
Whats needed next
Slide Number 87
newly dx ckd
Slide Number 89
Bibliography
bibliography
bibliography
bibliography
bibliography
Stage 12
Stage 3
Stage 4
Stage 5
Hb le10 gdL
52
56
11
272
Hb gt10-le12 gdL
216
359
426
483
Hb le12 gdL
267
416
536
755
Stage 12
Stage 3
Stage 4
Stage 5
USE THESE EQUATIONS CAUTIOUSLY IF AT ALL IN hellip
bull Patients who haveare
bull Poor nutritionloss of muscle mass
bull Amputation
bull Chronic illness
bull Not African American or Caucasian
bull Changing serum creatinine
bull Obese
bull Very elderly young
(National Kidney Foundation 2014)
LAB ALBUMIN CREATININE RATIO
bull Urinary albumin-to-creatinine ratio (ACR) is calculated by dividing albumin concentration in milligrams by creatinine concentration in grams
bull Creatinine assists in adjusting albumin levels for varying urine concentrations which allows for more accurate results versus albumin alone
bull Spot urine albumin-to-creatinine ratio for quantification of proteinuria
bull New guidelines classify albuminuria as mild moderately or severely increased
bull First morning void preferable
bull 24hr urine test rarely necessary
THE NEW CKD CATEGORIES
STEPS TO CKD PATIENT CARE
1 CKD definition and risks2 Assess GFR albuminuria3 Determine etiology- what is going on here4 Slow progression5 Assess for associated complications6 Discuss dialysistransplantation
(Pal 2012)
KIDNEY INVOLVEMENT IN SYSTEMIC DISEASES
Hypertension
DiabetesAmyloidosis
Sickle cell diseases
Immune complex GN
Illicit drugs ndash cocaine heroin
Cholesterol emboli
HIV
Allergic reactions- drugsinterstitial nephritis
Hemolytic Uremic syndrome
Lupus
Systemic vasculitis
Liver FailureCongestive heart Failure
Image retrieved on 05 October 2010 from httpenwikipediaorgwikiFileGray1129pngThis image is under the public domain and not copyrightable in the US as per Bridgeman Art Library v Corel Corp
(Vasudev amp Vasudev 2012)
New CKD
Obtain ultrasound UA
microscopy albumincr ratio
Ultrasound shows
obstruction
bull Yes Relieve obstruction
bull No Is there albuminuria or glomerular bleeding (eval for glomerulo-nephritis
Fatehi amp Chi-yuan 2016
If red cells have their typical shape and color this indicates extra glomerular hematuria
Examples kidney stone disease UTI cystitis bleeding from collecting duct ureters bladder or urethra
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileReactive_lymphJPGCreative Commons License associated httpcreativecommonsorglicensesby-sa30deeden
(Vasudev amp Vasudev 2012)
DYSMORPHICRENAL HEMATURIA
bull This hematuria is characterized by bull a great variation in the size of the cells and by a high
percentage of dysmorphocytosiscasts (gt20)
bull Hematuria is usually related to glomerular bleeding bull It is typically accompanied by variable levels of albumuniuria
(Vasudev amp Vasudev 2012)
Urinary Cast Formation
Urine Microscopy can be helpful in work up of chronic kidney disease
In GNrsquos the red blood cells leak from the glomerulus into the tubules As they traverse through the tubules they can form cylindrical casts calledRBC casts
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileRedbloodcellsjpgThis image is a work of the National Institutes of Health part of the United States Department of Health and Human Services As a work of the US federal government the image is in the public domain
(Vasudev amp Vasudev 2012)
IF YOU HAVE ALBUMINURIA OR HEMATURIA-ORDER THE FOLLOWING LABS
Tests of autoimmunity Hepatitis serologies gt40 years- paraproteinassessment
ANA Hepatitis B serology (HBsAG)
Serum protein electrophoresis (SPEP)
RFanti-ccp Hepatitis C serology(HCV antibody)
Urine protein electrophoresis (UPEP)
Complement C3 C4
ANCANational Kidney Disease Education Program 2014 NIH
UPTODATE LAB RECOMENDATIONS
bull Lab to order cbc cmp urine albumincr ratio urine microscopy
bull Nephrotic pattern (protein gt35gday) ANA anti DS DNA C3 and C4 antibodies HIV HBV HCV serumurine immunofixation (amyloidosis) free light chain analysis (light chain deposition disease)
bull Nephritic pattern (red cells white cells casts variable protein) C3 C4 ANA dsDNA antineutrophil cytoplasmic antibody (ANCA) titers a streptozyme test HBV and HCV serologies HIV and in some cases blood cultures anti-glomerular basement membrane (GBM) antibodies and cryoglobulins
bull Renal biopsy(Hebert amp Parikh 2014)
EVALUATION OF NEW CKDNO OBSTRUCTION
NO EVIDENCE OF GLOMERULAR BLEEDING
High risk for multmyeloma (gt40
no nsaids no contrast
SPEP UPEP with immunofixation serum free light
chains
Evaluation depends on UA
Sterile pyuria
Eval for interstitial nephritis
Normal urinalysis
High risk for renovascular
disease
Eval for renovascular
disease
Follow serum creatinine-does it
remain stable(Fatehi amp Chi-yuan 2016)
POSSIBLE INVESTIGATIONShellip
Acute interstitial nephritisbull Drugs are the most common cause of AIN
DIABETIC NEPHROPATHY 1 CAUSE OF CKDbull Clinical syndromebull Albuminuria gt30 mg 24 hrsbull Proteinuria gt500 mg24 hrsbull Hypertension developsbull Progressive increase in proteinuriabull Progressive decline in glomerular filtration rate
bull Chronic kidney disease should be attributed to diabetic nephropathies in most patients with diabetes if albuminuria and diabetic retinopathy are both present other causes of CKD should be entertained if diabetic retinopathy is absent (KDIGO 2007)
DIABETIC NEPHROPATHY MORTALITY
bull After 40 yrs of DM
bull 10 alive if proteinuria is present
bull 70 alive if proteinuria is absent
bull Heart Disease is 15 times higher risk in those with proteinuria
bull Proteinuria = death in this population
Dunkler et al 2015
GOALS OF CARE IN CKD GLUCOSE CONTROL
bull Target HbA1c ~70 (lt695 greatest chance of reducing albuminuria)bull Can be extended above 70 with comorbidities or limited life expectancy and
risk of hypoglycemiabull Risk of hypoglycemia increases as kidney function becomes impairedbull Declining kidney function may necessitate changes to diabetes medications and
bull Just having HTN can cause proteinuriabull Usually 1-2 gms of protein a daybull Treat them like a diabetic with ACEI or ARBS and tight blood
pressure controlbull JNC-8 goal lt14090 for ptrsquos with CKDbull National kidney foundation lt14090 if ckd and no proteinuria
lt13080 if proteinuria present
(James Ortiz amp Et Al 2014)
TREATING HYPERTENSIONPROTEINURIA ACEI ORARBbull Riskbenefit should be carefully assessed in the elderly and medically fragilebull Check labs after initiation
bull If less than 30 SCr increase continue and monitorbull If more than 30 SCr increase stop ACEi and evaluate for renal artery stenosis
bull Continue until contraindication arises no absolute eGFR cutoffbull Better proteinuria suppression with low Na diet and diureticsbull Avoid volume depletionbull Avoid ACEi and ARB in combination12
bull Risk of adverse events (impaired kidney function hyperkalemia)
(Kunz Friedrich Wolbers amp Mann 2008)(Mann Schmieder amp McQueen 2008)
bull In adults gt50 yrs statin when eGFR ge 60 mlmin173m2 statin or statinezetimibe combination when eGFR lt 60 mlmin173m2
bull In adults lt 50 yrs statin if history of known CAD MI DM strokebull Aspirin is indicated for secondary but not primary prevention
Kidney Disease Improving Global Outcomes (KDIGO) CKD Work Group Kidney Int Suppls 201331-150
STATINS-RENOPROTECTIVECONTROVERSY
bull HMG-CoA reductase inhibitors (statins) in high doses can cause proteinuria
bull Possibly associated with less inflammation endothelial dysfunction and scarring in the kidney because they also block inflammatory cytokines
bull Use statins for CV disease not to treat proteinuria
(Afzali and Goldsmith 2016)
MEDICINE CAUTION
bull Hold metformin when gfr lt35 mlmin
bull GFR lt50 mlmin should alert to check all doses of meds
bull No bisphosphanates lt35 mlmin
bull No NSAIDScox 2 inhibitors lt60 mlmin
bull Atenolol ndashrenal excretion
bull BACTRIM A lot of AKI
MEDICINE CAUTION
bull Lovenox-use subcut heparinbull Apixibanbull Dabigatranbull Rivaroxibanbull Lithiumbull GABAPENTIN (ckd 4 max 300mg qd ckd 5 max 300mg qod)
STEPS TO CKD PATIENT CARE
1 CKD definition and risks2 Assess GFR albuminuria3 Determine etiology4 Assess for evidence of progression5 Assess for associated complications6 Discuss dialysistransplantation
CKD-CVD-DIABETES LINK CKD IS A DISEASE MULTIPLIER
National kidney foundation 2014
KDIGO 2017
CKD-MINERAL BONE DISORDERS
bull As kidneys fail they
bull Stop activating calcitriol (the active form of Vit D)mdashcausing calcium imbalance
bull Do not remove phosphorus from bloodmdashleading to phosphorus retention
bull The extra phosphorus pulls calcium out of bones causing them to weaken
bull High phosphorus stimulates PTH release
bull These changes (plus others) cause the start of secondary hyperparathyroidism
bull Labs
bull eGFR
bull Calcium
bull Phos
bull Vit D
bull iPTH
(Qunibi amp Henrich 2017)
PREVALENCE OF ABNORMALITIES OF MINERAL METABOLISM PTH IN CKD
bull Progression of disease ndash declining eGFR increasing proteinuria
bull Degree of proteinuria nephrotic syndrome gt 05-10 gd on ACEi or ARB therapy
bull Etiology of CKD not certain
bull Need help with disease management
bull Indications for kidney biopsy
Rosenberg 2016
WHEN TO REFER
STEPS TO CKD PATIENT CARE
1 CKD definition and risks2 Assess GFR albuminuria3 Determine etiology4 Assess for evidence of progression5 Assess for associated complications6 Discuss dialysistransplantation
KIDNEY TRANSPLANTATION
bull Treatment of choice for ESRDbull Improves quality of lifebull Waiting list time varies-3-5 yearsbull 3 year survival rate after transplantation is 83-94bull Increased risk of cancer
STARTING DIALYSIS IN THE ELDERLYhellipOR NOT
bull Among patients gt 75 yrs with stage 5 CKD who chose to NOT start dialysisbull Overall more likely to die over next 1-2 years bull But if they had ischemic heart disease or other significant comorbidity NO
DIFFERENCE in survival
bull Active disease management and supportive care may be appropriate without starting dialysis in the ill elderly
bull Palliative care does not mean ldquono carerdquo
bull Must have end-of-life discussions
(Murtagh et al 2007)
CKD MANAGEMENTbull Diagnose cause and treat underlying conditionbull Stage per guidelinesbull Slow progression of kidney disease (ACE inhibitors)bull Monitor for complicationsmdashvolume overload hyperkalemia metabolic acidosis
hyperphosphatemia anorexia fatigue htn bone diseasebull Labs cmp cbc phos Vit D 25OH iPTH urine microscopy uric acid urine
proteincr ratio-frequency based off heat map Get sono at least oncebull Vaccinate influenza hep B pneumococcalbull Eval ASCVD risk-likely needs statinbull Possible dexa (donrsquot give bisphosphonates if GFRlt35 let specialist manage)bull Refer to nephrology when eGFR is lt30 (sometimes if higher risk-refer earlier)
CASE 1
bull 55 year old man with past medical history of headaches presents to your office for his first time visit to a PCP in over 30 years
bull He has no past history of being admitted to the hospital and he does not take any OTC medsNSAIDsherbal meds He has no history of ETOH abuse smoking or drug use
bull Vitals BP 180100 mmHg pulse 80 R 18
bull Exam No JVD S1S2 regular PMI shifted to the left no gallop no abdominal bruit pulses bilaterally equal and regular no leg edema
bull What would you order
bull EKG cbc cmp ua urine proteincr ratio lipid
LAB RESULTS
bull Labs reveal a creatinine of 22 mgdL eGFR 33 Urine shows no blood or casts Urineprotein ratio shows 1 gm protein24 hrs EKG shows LVH
bull Next step in workupbull Renal ultrasound 1st then SPEP UPEP with immunofixation serum free light chains
bull Additional labs neg Renal ultrasound shows that both kidneys are slightly reduced in size and are mildly echogenic with no mass or hydronephrosis
bull What is your diagnosis
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileMain_complications_of_persistent_high_blood_pressurepngCreative Commons License associated httpcreativecommonsorglicensesby-sa30
bull 3 months Howevermdashwe have evidence of structural abnormalities Could potentially stage at G3b A3 (red on the heat map)
bull Goal blood pressure
bull JNC 8 14090 NKF 13080
bull Additional lab needed for progression monitoring
bull Cbc renal panel phos Vit D iPTH uric acid urine micro (we already have the renal sono and urine proteincr ratio and lipid)
Selective renal angiography (left lower renal artery) after successful percutaneous balloon dilatation of the stenotic lesionFibromuscular dysplasia in an accessory renal artery causing renovascular hypertension
Secondary Hypertension
Images retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileRenal_FMD2jpg and httpcommonswikimediaorgwikiFileRenal_FMDjpgCreative Commons License associated httpcreativecommonsorglicensesby20deeden (both images)
CASE 2bull OS is a 64year old Hispanic female in for DM check She has had DM for 15+ years and is currently
taking metformin 1000mg bid Lisinopril 10mg a day atorvastatin 40mg a day Labs today showed the following
bull Hgba1c 86 cmp eGFR 50 lipid WNL proteincr ratio 650mg These results are similar to her last visit
bull Upon further hx-you find that she had a recent eye exam and has mild nonproliferaive retinopathy She does not have neuropathy or other ss
bull What further workup do you need
bull Renal sonogram urine micro iPTH vit D (25 OH) phos uric acid
bull Dx stage
bull G3a A3
bull What further treatment do you need
bull Improve glycemic control Increase Lisinopril to 20mg with a goal of 40mg Avoid NSAIDs or other nephrotoxic agents make sure meds are renally dosed monitor 3xyear nephro referral
MANAGEMENT OF CKD IN DIABETESeGFR Recommended
All patients
Yearly measurement of creatinine urinary albumin excretion potassium
45-60 Referral to a nephrologist if possibility for nondiabetickidney disease existsConsider dose adjustment of medicationsMonitor eGFR every 6 monthsMonitor electrolytes bicarbonate hemoglobin calcium phosphorus parathyroid hormone at least yearly
Assure vitamin D sufficiencyConsider bone density testingReferral for dietary counselling
American Diabetes Association Standards of Medical Care in Diabetes Microvascular complications and foot care Diabetes Care 2017 40 (Suppl 1) S88-S98
CASE 3
bull 19 year old African American woman presents to your clinic with complaints of fatigue joint pains a new rash on her face oral ulcer
bull On exam BP 15080 P 88 Afebrile 96 O2 sats on RAbull GEN No respiratory distress at restbull HEENT painless oral ulcer flat rash over malar eminences sparing the nasolabial fold pallor +bull Lungs CTAbull CVS S1S2 regularbull Abdomen soft NTbull Ext left elbow joint and bilateral wrist joints are swollen and tender
bull What would you orderbull CBC CMP ua urine microscopy (microalbumin or urine proteincr ratio) ANA esr RF anti-ccp uric acid TSH
CASE 3
bull Working dx fatigue oral ulcer joint pain
bull Basic Labs Na 135 K 55 Bicarb 18 BUN 50 Cr 35 eGFR 22 Ca 90 ANA + titer 1640
bull UA 3+ blood 3+ protein RBC casts +
bull Given these results what is the most likely diagnosis
bull What would you do
SYSTEMIC LUPUS ERYTHEMATOSUS (SLE)
bull SLE multisystemic disease Etiology unknown
bull Production of autoantibodies and immune complexes formation
bull There is renal involvement in the great majority of patients with SLE at some time of the evolution 66-90
SLE ndash LUPUS NEPHRITIS
bull Race SLE is more commonsevere in African americans than Caucasiansbull
bull Gender female-to-male ratio of 91
bull Age Most patients develop lupus nephritis early in their disease course SLE is more common among women in the third decade of life and lupus nephritis occurs in patients aged 20-40 years
bull Kidney Biopsy For staging lupus nephritis (Class 1-5)
CASE 5bull A 80 year old man who has not seen a PCP in many years
presents to your clinic for weakness for the past few months On further questioning he tells you that his bones also have been hurting lately and he has developed leg swelling in the past month or so
bull On exam bull BP 16090 P 88 Afebrilebull GEN Thin built manbull HEENT pallor presentbull Lungs clearbull CVS S1S2 regular no rub or gallopbull Abdomen soft NTbull Ext 2 + edema
CASE 5
bull Differentials
bull CHF MI Cancer arthritis
bull Labs
bull CBC CMP urine microscopy urine proteincr ratio ESR TSH EKG BNP pa and lat CXR
bull LABS Urine dipstick negative for protein or blood
bull Basic chem bull Na 136 (135-145) K 51 (35-55) Chloride 108 (96-106) Bicarb 25
Given this presentation and the labs (low anion gap and elevated calcium anemia kidney failure) what will you think of What will you order next
Serum and urine protein electrophoresis
Intratubular refractile casts with surrounding syncytial giant cell reaction with chronic tubulointerstitial nephritis and fibrosis characteristic of myeloma cast nephropathy
Kidney Biopsy
CASE STUDYbull A 35 year old African American woman was seen in the clinic for
chronic cough and dyspnea on exertion She gave history of vague symptoms of fatigue and weight loss of 20 Ibs over the last six months
bull List some differentialsbull TB sarcoid lupus thyroid problems PEbull What would you orderbull PPD cbc cmp UA TSH ANA pa and lat cxr
bull Her labs were significant for mildly elevated calcium level and a creatinine of 20 mgdL eGFR 37
bull She had 750 mg of proteinuriaday
bull PPD neg ANA neg TSH and other labs WNL
bull Assuming this is present more than 3 monthshelliphellipwhat is her ckd stage
bull G3b A3
bull What do we still need
CT scan of chest
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileAnterior_mediastinal_mass_thymomajpgCreative Commons License associated httpcreativecommonsorglicensesby20deeden
CXR ndash HILAR LYMPHADENOPATHY
WHATS NEEDED NEXT
bull Biopsy of hilar lymphadenopathy or renal biopsy
bull DX sarcoidosis
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileSarcoidosis_signs_and_symptomsjpgThis work is in the public domain in the United States because it is a work of the United States Federal Government under the terms of Title 17 Chapter 1 Section 105 of the US Code
NEWLY DX CKD
bull 1) urinalysis microscopy ultrasound proteincr ratio
bull If obstruction-treat
bull No obstruction
bull Hx critical (consider myeloma if high risk)
bull glomerular bleeding or albumin in urine
bull Yes workup for glomerular causes (ANArf hep B C upep spep ANCA complement C3 C4)
bull No sterile pyruria-consider interstitial nephritis
bull High risk renovascular disease Evaluate renovascular disease
Additional Online Resources for CKD LearningbullNational Kidney Foundation wwwkidneyorgbullUnited States Renal Data Service wwwusrdsorgbullCDCrsquos CKD Surveillance Project
httpnccdcdcgovckdbullNational Kidney Disease Education Program
(NKDEP) httpnkdepnihgov
BIBLIOGRAPHY
bull Afzali B amp Goldsmith D J (2016 June 29) Statins and chronic kidney disease (G C Curhan amp A M Sheridan Eds) Retrieved 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsstatins-and-chronic-kidney-disease
bull American Diabetes Association Standards of Medical Care in Diabetes (2017) Microvascular complications and foot care Diabetes Care 2017 (40) S88-S98
bull American Diabetes Association Standards of Medical Care in Diabetes (2017) Microvascular complications and foot care Diabetes Care 40 (suppl 1) S88-S98
bull Berns J S (2017 Mar 22) Treatment of anemia in nondialysis chronic kidney disease (T A Golper amp A M Sheridan Eds) Retrieved from UpToDate httpswww-uptodate-comproxywichitaeducontentstreatment-of-anemia-in-nondialysis-chronic-kidney-disease
bull Chan M Dall A T Fletcher K E Lu N amp Trivedi H (2007) Outcomes in patients with chronic kidney disease referred late to nephrologists a meta-analysis American Journal of Medicine 120(12) 1063-1070
bull Coresh J Selvin E amp Stevens L A (2007) Prevalence of chronic kidny disease in the United States JAMA 298(17) doi101001jama298172038
bull de Brito-Ashurst I Varagunam M Raftery M amp Yagoob M (2009) Bicarbonate supplementation slows progression of CKD and improves nutritional status Journal of American Society of Nephrology (20) 2075-2084
BIBLIOGRAPHY
bull Duncan L Heathcoat J Djurdjev O amp Levin A (2001) Screening for renal disease using serum creatinine who are we missing Nephrology Dialysis and Transplant 16(5) 1042-1046
bull Dunkler D Gao P Lee S F Heinz G Clase C M Tobe S Oberbauer R (2015 August 7) Risk prediction for early CKD in type 2 diabetes Retrieved from Clinical Journal of the American Society of Nephrology httpcjasnasnjournalsorgcontent1081371fullsid=61422554-a5f1-41ac-b696-dcd3b12bd268
bull Fatehi P amp Chi-yuan H (September 15 2016) Diagnostic approach to the patient with newly identified chronic kidney disease (G C Curhan amp A M Sheridan Eds) Retrieved May 7 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsdiagnostic-approach-to-the-patient-with-newly-identified-chronic-kidney-disease
bull Fink J e (2009) Chronic Kidney Disease as an Under-Recognized Threat to Patient Safety American journal of kidney diseases the official journal of the National Kidney Foundation 53(4) 681-688
bull Gaffo A L amp Saag K G (2008 Nov) Management of hyperuricemia and gout in CKD doihttpdxdoiorg101053jajkd200807035
bull Hebert L A amp Parikh S V (2014 June 18) Differential diagnosis and evaluation of glomerular disease (R J Glassock amp A Q Lam Eds) Retrieved May 7 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsdifferential-diagnosis-and-evaluation-of-glomerular-disease
bull Inker L Perrone R D Sterns R H amp Forman J P (2017 March 7) Assessment of kidney function Retrieved from UpToDate httpswww-uptodate-comproxywichitaeducontentsassessment-of-kidney-functionsource=search_resultampsearch=creatinineampselectedTitle=1~150
BIBLIOGRAPHY
bull James P A Ortiz E amp Et Al (2014) Evidence based guideline for the management of high blood pressure in adults (JNC) JAMA 311(5) 507-520
bull Kidney Disease Improving Global Outcomes (KDIGO) CKD Work Group (2013 January) KDIGO 2012 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease Retrieved from Kidney International Supplement httpwwwkidney-internationalorg
bull Kunz R Friedrich C Wolbers M amp Mann J F (2008) Meta-analysis effect of monotherapy and combination therapy with inhibitors of the renin angiotensin system on proteinuria in renal disease Annals of Internal Medicine 148(1) 30-48
bull Levey A Stevens L A Schmid C H Castro A F Feldman H I Kusek J W Coresh J (2009) A new equation to estimate glomerular filtration rate Annals of Internal Medicine 150(9) 604-612
bull Levin A Bakris G L Molitch M Smulders M M Williams L A amp Andress D L (2007 Jan) Prevalence of abnormal serum vitamin D PTH calcium and phosphorus in patients with chronic kidney disease results of the study to evaluate early kidney disease Kidney International 71(1) 31-38 Retrieved from PubMED
bull Mahajan A Simoni J Sheather S Broglio K Rajab M amp Wesson D (2010) Daily oral sodium bicarbonate preserves glomerular filtration rate by slowing its decline in early hypertensive nephropathy Kidney International (78_ 303-309
bull Mann J Schmieder R E amp McQueen M (2008) Renal outcomes with telmisartan ramipril or both in people at high vascular risk (the ONTARGET study) a multicentre randomised doubleblind ocntrolled trial Lancet 372(9638) 547-533
BIBLIOGRAPHY
bull Matovinović M S (2009) Pathophysiology and classification of kidney disease Retrieved from The Journal of the International Federation of Clinical Chemistry and Laboratory Medicine httpwwwifccorgifccfilesdocs20010902pdf
bull Moe S Drueke T Lameire N amp Eknoyan G (2007 Jan) Chronic kidney disease-mineral-bone disorder a new paradigmdoi101053jackd200610005
bull Murtagh F E Marsh J E Donohoe P Ekbal N J Sheerin N S amp Harris F E (2007 July) Dialysis or not A comparative survival study of patients over 75 years with chronic kidney disease stage 5 Retrieved from Nephrology Dialysis and Transplant 22(7) httpswwwncbinlmnihgovpubmed17412702
bull National Kidney Foundation (2002) KDOQI clinical practice guidelines for chronic kidney disease evaluation classification andstratification American Journal of Kidney Disease S1-S266
bull National Kidney Foundation (2014 November 5) Fact Sheets Retrieved from httpwwwkidneyorgnewsnewsroomfactsheetsFastFacts
bull Pal S (2012 June 2) Trends in chronic kidney disease Retrieved from US Pharmacist (37)6 httpswwwuspharmacistcomarticletrends-in-chronic-kidney-disease
bull Qunibi W amp Henrich W L (2017 Jan 19) Overview of chronic kidney disease-mineral and bone disorder (J Berns amp A M Sheridan Eds) Retrieved from UpToDate httpswww-uptodate-comoverview-of-chronic-kidney-disease-mineral-and-bone-disorder-ckd-mbd
bull Rosenberg M (2016 Feb 24) Overview of the management of chronic kidney disease in adults (G C Curhan amp A M Sheridan Eds) Retrieved from UpToDate UpToDate httpswww-uptodate-comproxywichitaeducontentsoverview-of-the-management-of-chronic-kidney-disease-in-adults
BIBLIOGRAPHY
bull Szczech L Stewart R C Hsu-Lin S DeLosky R J Astor B C Fox C H Vassalotti J A (2014) Primary care detection of chronic kidney disease in adults with type 2 diabetes The ADD-CKD Study (Awareness Detection and Drug Therapy in type 2 diabetes and chronic kidney disease PLOS doihttpsdoiorg101371journalpone0110535
bull USRDS (2016) Annual data report 2016 Epidemiology of kidney disease in the United States Retrieved from United States Renal Data System httpswwwusrdsorgadraspx
bull Vasudev B amp Vasudev M (2012) A model curriculum for residents rotating in nephrology MedEDPORTAL doihttpdoiorg1015766mep_2374-82658288
bull Wei L MacDonald T M Jennings C Sheng X amp Flynn R W (2013) Estimated GFR reporting is associated with decreased nonsteroidal anti-inflammatory drug prescribing and increased renal function Kidney International (84)1 174-178
chronic kidney disease in primary care
CKD as a Public Health Issue
Slide Number 3
Costs of CKD in 2013 dollarsUSRDS report
Steps to CKD Patient Care
Renal anatomy and physiology
Definition of Chronic Kidney Disease
CKD Risk Factors
Gaps in CKD Diagnosis
Slide Number 10
Steps to CKD Patient Care
creatinine
Glomerular filtration rate
Slide Number 14
Slide Number 15
Use These Equations Cautiously if at all in hellip
lab albumin creatinine ratio
The New CKD Categories
Steps to CKD Patient Care
Slide Number 20
Kidney Involvement in Systemic Diseases
Slide Number 22
Slide Number 23
DysmorphicRenal Hematuria
Slide Number 25
If you have albuminuria or hematuria-order the following labs
Prevalence of Abnormalities of Mineral Metabolism PTH in CKD
Managing CKD-MBD complications
CKD-MBD Testing
Anemia Becomes More Common as Kidney Function Declines
Detect and Manage CKD Complications
Complications-metabolic acidosis
Complications-vascular calcification
Hyperkalemia management
Hyperuricemia levels amp CKD
CKD monitoring levels 345
Slide Number 59
When to Refer to a Nephrologist
When to Refer
Steps to CKD Patient Care
Kidney transplantation
Starting Dialysis in the ElderlyhellipOr Not
Ckd management
Case 1
Slide Number 67
Lab results
Slide Number 69
Hypertensive nephropathy with proteinuria
Slide Number 71
Case 2
Slide Number 73
Management of CKD in Diabetes
Case 3
Case 3
Systemic Lupus Erythematosus (SLE)
SLE ndash Lupus Nephritis
Case 5
Case 5
Slide Number 81
Slide Number 82
Case study
Slide Number 84
CXR ndash Hilar Lymphadenopathy
Whats needed next
Slide Number 87
newly dx ckd
Slide Number 89
Bibliography
bibliography
bibliography
bibliography
bibliography
Stage 12
Stage 3
Stage 4
Stage 5
Hb le10 gdL
52
56
11
272
Hb gt10-le12 gdL
216
359
426
483
Hb le12 gdL
267
416
536
755
Stage 12
Stage 3
Stage 4
Stage 5
LAB ALBUMIN CREATININE RATIO
bull Urinary albumin-to-creatinine ratio (ACR) is calculated by dividing albumin concentration in milligrams by creatinine concentration in grams
bull Creatinine assists in adjusting albumin levels for varying urine concentrations which allows for more accurate results versus albumin alone
bull Spot urine albumin-to-creatinine ratio for quantification of proteinuria
bull New guidelines classify albuminuria as mild moderately or severely increased
bull First morning void preferable
bull 24hr urine test rarely necessary
THE NEW CKD CATEGORIES
STEPS TO CKD PATIENT CARE
1 CKD definition and risks2 Assess GFR albuminuria3 Determine etiology- what is going on here4 Slow progression5 Assess for associated complications6 Discuss dialysistransplantation
(Pal 2012)
KIDNEY INVOLVEMENT IN SYSTEMIC DISEASES
Hypertension
DiabetesAmyloidosis
Sickle cell diseases
Immune complex GN
Illicit drugs ndash cocaine heroin
Cholesterol emboli
HIV
Allergic reactions- drugsinterstitial nephritis
Hemolytic Uremic syndrome
Lupus
Systemic vasculitis
Liver FailureCongestive heart Failure
Image retrieved on 05 October 2010 from httpenwikipediaorgwikiFileGray1129pngThis image is under the public domain and not copyrightable in the US as per Bridgeman Art Library v Corel Corp
(Vasudev amp Vasudev 2012)
New CKD
Obtain ultrasound UA
microscopy albumincr ratio
Ultrasound shows
obstruction
bull Yes Relieve obstruction
bull No Is there albuminuria or glomerular bleeding (eval for glomerulo-nephritis
Fatehi amp Chi-yuan 2016
If red cells have their typical shape and color this indicates extra glomerular hematuria
Examples kidney stone disease UTI cystitis bleeding from collecting duct ureters bladder or urethra
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileReactive_lymphJPGCreative Commons License associated httpcreativecommonsorglicensesby-sa30deeden
(Vasudev amp Vasudev 2012)
DYSMORPHICRENAL HEMATURIA
bull This hematuria is characterized by bull a great variation in the size of the cells and by a high
percentage of dysmorphocytosiscasts (gt20)
bull Hematuria is usually related to glomerular bleeding bull It is typically accompanied by variable levels of albumuniuria
(Vasudev amp Vasudev 2012)
Urinary Cast Formation
Urine Microscopy can be helpful in work up of chronic kidney disease
In GNrsquos the red blood cells leak from the glomerulus into the tubules As they traverse through the tubules they can form cylindrical casts calledRBC casts
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileRedbloodcellsjpgThis image is a work of the National Institutes of Health part of the United States Department of Health and Human Services As a work of the US federal government the image is in the public domain
(Vasudev amp Vasudev 2012)
IF YOU HAVE ALBUMINURIA OR HEMATURIA-ORDER THE FOLLOWING LABS
Tests of autoimmunity Hepatitis serologies gt40 years- paraproteinassessment
ANA Hepatitis B serology (HBsAG)
Serum protein electrophoresis (SPEP)
RFanti-ccp Hepatitis C serology(HCV antibody)
Urine protein electrophoresis (UPEP)
Complement C3 C4
ANCANational Kidney Disease Education Program 2014 NIH
UPTODATE LAB RECOMENDATIONS
bull Lab to order cbc cmp urine albumincr ratio urine microscopy
bull Nephrotic pattern (protein gt35gday) ANA anti DS DNA C3 and C4 antibodies HIV HBV HCV serumurine immunofixation (amyloidosis) free light chain analysis (light chain deposition disease)
bull Nephritic pattern (red cells white cells casts variable protein) C3 C4 ANA dsDNA antineutrophil cytoplasmic antibody (ANCA) titers a streptozyme test HBV and HCV serologies HIV and in some cases blood cultures anti-glomerular basement membrane (GBM) antibodies and cryoglobulins
bull Renal biopsy(Hebert amp Parikh 2014)
EVALUATION OF NEW CKDNO OBSTRUCTION
NO EVIDENCE OF GLOMERULAR BLEEDING
High risk for multmyeloma (gt40
no nsaids no contrast
SPEP UPEP with immunofixation serum free light
chains
Evaluation depends on UA
Sterile pyuria
Eval for interstitial nephritis
Normal urinalysis
High risk for renovascular
disease
Eval for renovascular
disease
Follow serum creatinine-does it
remain stable(Fatehi amp Chi-yuan 2016)
POSSIBLE INVESTIGATIONShellip
Acute interstitial nephritisbull Drugs are the most common cause of AIN
DIABETIC NEPHROPATHY 1 CAUSE OF CKDbull Clinical syndromebull Albuminuria gt30 mg 24 hrsbull Proteinuria gt500 mg24 hrsbull Hypertension developsbull Progressive increase in proteinuriabull Progressive decline in glomerular filtration rate
bull Chronic kidney disease should be attributed to diabetic nephropathies in most patients with diabetes if albuminuria and diabetic retinopathy are both present other causes of CKD should be entertained if diabetic retinopathy is absent (KDIGO 2007)
DIABETIC NEPHROPATHY MORTALITY
bull After 40 yrs of DM
bull 10 alive if proteinuria is present
bull 70 alive if proteinuria is absent
bull Heart Disease is 15 times higher risk in those with proteinuria
bull Proteinuria = death in this population
Dunkler et al 2015
GOALS OF CARE IN CKD GLUCOSE CONTROL
bull Target HbA1c ~70 (lt695 greatest chance of reducing albuminuria)bull Can be extended above 70 with comorbidities or limited life expectancy and
risk of hypoglycemiabull Risk of hypoglycemia increases as kidney function becomes impairedbull Declining kidney function may necessitate changes to diabetes medications and
bull Just having HTN can cause proteinuriabull Usually 1-2 gms of protein a daybull Treat them like a diabetic with ACEI or ARBS and tight blood
pressure controlbull JNC-8 goal lt14090 for ptrsquos with CKDbull National kidney foundation lt14090 if ckd and no proteinuria
lt13080 if proteinuria present
(James Ortiz amp Et Al 2014)
TREATING HYPERTENSIONPROTEINURIA ACEI ORARBbull Riskbenefit should be carefully assessed in the elderly and medically fragilebull Check labs after initiation
bull If less than 30 SCr increase continue and monitorbull If more than 30 SCr increase stop ACEi and evaluate for renal artery stenosis
bull Continue until contraindication arises no absolute eGFR cutoffbull Better proteinuria suppression with low Na diet and diureticsbull Avoid volume depletionbull Avoid ACEi and ARB in combination12
bull Risk of adverse events (impaired kidney function hyperkalemia)
(Kunz Friedrich Wolbers amp Mann 2008)(Mann Schmieder amp McQueen 2008)
bull In adults gt50 yrs statin when eGFR ge 60 mlmin173m2 statin or statinezetimibe combination when eGFR lt 60 mlmin173m2
bull In adults lt 50 yrs statin if history of known CAD MI DM strokebull Aspirin is indicated for secondary but not primary prevention
Kidney Disease Improving Global Outcomes (KDIGO) CKD Work Group Kidney Int Suppls 201331-150
STATINS-RENOPROTECTIVECONTROVERSY
bull HMG-CoA reductase inhibitors (statins) in high doses can cause proteinuria
bull Possibly associated with less inflammation endothelial dysfunction and scarring in the kidney because they also block inflammatory cytokines
bull Use statins for CV disease not to treat proteinuria
(Afzali and Goldsmith 2016)
MEDICINE CAUTION
bull Hold metformin when gfr lt35 mlmin
bull GFR lt50 mlmin should alert to check all doses of meds
bull No bisphosphanates lt35 mlmin
bull No NSAIDScox 2 inhibitors lt60 mlmin
bull Atenolol ndashrenal excretion
bull BACTRIM A lot of AKI
MEDICINE CAUTION
bull Lovenox-use subcut heparinbull Apixibanbull Dabigatranbull Rivaroxibanbull Lithiumbull GABAPENTIN (ckd 4 max 300mg qd ckd 5 max 300mg qod)
STEPS TO CKD PATIENT CARE
1 CKD definition and risks2 Assess GFR albuminuria3 Determine etiology4 Assess for evidence of progression5 Assess for associated complications6 Discuss dialysistransplantation
CKD-CVD-DIABETES LINK CKD IS A DISEASE MULTIPLIER
National kidney foundation 2014
KDIGO 2017
CKD-MINERAL BONE DISORDERS
bull As kidneys fail they
bull Stop activating calcitriol (the active form of Vit D)mdashcausing calcium imbalance
bull Do not remove phosphorus from bloodmdashleading to phosphorus retention
bull The extra phosphorus pulls calcium out of bones causing them to weaken
bull High phosphorus stimulates PTH release
bull These changes (plus others) cause the start of secondary hyperparathyroidism
bull Labs
bull eGFR
bull Calcium
bull Phos
bull Vit D
bull iPTH
(Qunibi amp Henrich 2017)
PREVALENCE OF ABNORMALITIES OF MINERAL METABOLISM PTH IN CKD
bull Progression of disease ndash declining eGFR increasing proteinuria
bull Degree of proteinuria nephrotic syndrome gt 05-10 gd on ACEi or ARB therapy
bull Etiology of CKD not certain
bull Need help with disease management
bull Indications for kidney biopsy
Rosenberg 2016
WHEN TO REFER
STEPS TO CKD PATIENT CARE
1 CKD definition and risks2 Assess GFR albuminuria3 Determine etiology4 Assess for evidence of progression5 Assess for associated complications6 Discuss dialysistransplantation
KIDNEY TRANSPLANTATION
bull Treatment of choice for ESRDbull Improves quality of lifebull Waiting list time varies-3-5 yearsbull 3 year survival rate after transplantation is 83-94bull Increased risk of cancer
STARTING DIALYSIS IN THE ELDERLYhellipOR NOT
bull Among patients gt 75 yrs with stage 5 CKD who chose to NOT start dialysisbull Overall more likely to die over next 1-2 years bull But if they had ischemic heart disease or other significant comorbidity NO
DIFFERENCE in survival
bull Active disease management and supportive care may be appropriate without starting dialysis in the ill elderly
bull Palliative care does not mean ldquono carerdquo
bull Must have end-of-life discussions
(Murtagh et al 2007)
CKD MANAGEMENTbull Diagnose cause and treat underlying conditionbull Stage per guidelinesbull Slow progression of kidney disease (ACE inhibitors)bull Monitor for complicationsmdashvolume overload hyperkalemia metabolic acidosis
hyperphosphatemia anorexia fatigue htn bone diseasebull Labs cmp cbc phos Vit D 25OH iPTH urine microscopy uric acid urine
proteincr ratio-frequency based off heat map Get sono at least oncebull Vaccinate influenza hep B pneumococcalbull Eval ASCVD risk-likely needs statinbull Possible dexa (donrsquot give bisphosphonates if GFRlt35 let specialist manage)bull Refer to nephrology when eGFR is lt30 (sometimes if higher risk-refer earlier)
CASE 1
bull 55 year old man with past medical history of headaches presents to your office for his first time visit to a PCP in over 30 years
bull He has no past history of being admitted to the hospital and he does not take any OTC medsNSAIDsherbal meds He has no history of ETOH abuse smoking or drug use
bull Vitals BP 180100 mmHg pulse 80 R 18
bull Exam No JVD S1S2 regular PMI shifted to the left no gallop no abdominal bruit pulses bilaterally equal and regular no leg edema
bull What would you order
bull EKG cbc cmp ua urine proteincr ratio lipid
LAB RESULTS
bull Labs reveal a creatinine of 22 mgdL eGFR 33 Urine shows no blood or casts Urineprotein ratio shows 1 gm protein24 hrs EKG shows LVH
bull Next step in workupbull Renal ultrasound 1st then SPEP UPEP with immunofixation serum free light chains
bull Additional labs neg Renal ultrasound shows that both kidneys are slightly reduced in size and are mildly echogenic with no mass or hydronephrosis
bull What is your diagnosis
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileMain_complications_of_persistent_high_blood_pressurepngCreative Commons License associated httpcreativecommonsorglicensesby-sa30
bull 3 months Howevermdashwe have evidence of structural abnormalities Could potentially stage at G3b A3 (red on the heat map)
bull Goal blood pressure
bull JNC 8 14090 NKF 13080
bull Additional lab needed for progression monitoring
bull Cbc renal panel phos Vit D iPTH uric acid urine micro (we already have the renal sono and urine proteincr ratio and lipid)
Selective renal angiography (left lower renal artery) after successful percutaneous balloon dilatation of the stenotic lesionFibromuscular dysplasia in an accessory renal artery causing renovascular hypertension
Secondary Hypertension
Images retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileRenal_FMD2jpg and httpcommonswikimediaorgwikiFileRenal_FMDjpgCreative Commons License associated httpcreativecommonsorglicensesby20deeden (both images)
CASE 2bull OS is a 64year old Hispanic female in for DM check She has had DM for 15+ years and is currently
taking metformin 1000mg bid Lisinopril 10mg a day atorvastatin 40mg a day Labs today showed the following
bull Hgba1c 86 cmp eGFR 50 lipid WNL proteincr ratio 650mg These results are similar to her last visit
bull Upon further hx-you find that she had a recent eye exam and has mild nonproliferaive retinopathy She does not have neuropathy or other ss
bull What further workup do you need
bull Renal sonogram urine micro iPTH vit D (25 OH) phos uric acid
bull Dx stage
bull G3a A3
bull What further treatment do you need
bull Improve glycemic control Increase Lisinopril to 20mg with a goal of 40mg Avoid NSAIDs or other nephrotoxic agents make sure meds are renally dosed monitor 3xyear nephro referral
MANAGEMENT OF CKD IN DIABETESeGFR Recommended
All patients
Yearly measurement of creatinine urinary albumin excretion potassium
45-60 Referral to a nephrologist if possibility for nondiabetickidney disease existsConsider dose adjustment of medicationsMonitor eGFR every 6 monthsMonitor electrolytes bicarbonate hemoglobin calcium phosphorus parathyroid hormone at least yearly
Assure vitamin D sufficiencyConsider bone density testingReferral for dietary counselling
American Diabetes Association Standards of Medical Care in Diabetes Microvascular complications and foot care Diabetes Care 2017 40 (Suppl 1) S88-S98
CASE 3
bull 19 year old African American woman presents to your clinic with complaints of fatigue joint pains a new rash on her face oral ulcer
bull On exam BP 15080 P 88 Afebrile 96 O2 sats on RAbull GEN No respiratory distress at restbull HEENT painless oral ulcer flat rash over malar eminences sparing the nasolabial fold pallor +bull Lungs CTAbull CVS S1S2 regularbull Abdomen soft NTbull Ext left elbow joint and bilateral wrist joints are swollen and tender
bull What would you orderbull CBC CMP ua urine microscopy (microalbumin or urine proteincr ratio) ANA esr RF anti-ccp uric acid TSH
CASE 3
bull Working dx fatigue oral ulcer joint pain
bull Basic Labs Na 135 K 55 Bicarb 18 BUN 50 Cr 35 eGFR 22 Ca 90 ANA + titer 1640
bull UA 3+ blood 3+ protein RBC casts +
bull Given these results what is the most likely diagnosis
bull What would you do
SYSTEMIC LUPUS ERYTHEMATOSUS (SLE)
bull SLE multisystemic disease Etiology unknown
bull Production of autoantibodies and immune complexes formation
bull There is renal involvement in the great majority of patients with SLE at some time of the evolution 66-90
SLE ndash LUPUS NEPHRITIS
bull Race SLE is more commonsevere in African americans than Caucasiansbull
bull Gender female-to-male ratio of 91
bull Age Most patients develop lupus nephritis early in their disease course SLE is more common among women in the third decade of life and lupus nephritis occurs in patients aged 20-40 years
bull Kidney Biopsy For staging lupus nephritis (Class 1-5)
CASE 5bull A 80 year old man who has not seen a PCP in many years
presents to your clinic for weakness for the past few months On further questioning he tells you that his bones also have been hurting lately and he has developed leg swelling in the past month or so
bull On exam bull BP 16090 P 88 Afebrilebull GEN Thin built manbull HEENT pallor presentbull Lungs clearbull CVS S1S2 regular no rub or gallopbull Abdomen soft NTbull Ext 2 + edema
CASE 5
bull Differentials
bull CHF MI Cancer arthritis
bull Labs
bull CBC CMP urine microscopy urine proteincr ratio ESR TSH EKG BNP pa and lat CXR
bull LABS Urine dipstick negative for protein or blood
bull Basic chem bull Na 136 (135-145) K 51 (35-55) Chloride 108 (96-106) Bicarb 25
Given this presentation and the labs (low anion gap and elevated calcium anemia kidney failure) what will you think of What will you order next
Serum and urine protein electrophoresis
Intratubular refractile casts with surrounding syncytial giant cell reaction with chronic tubulointerstitial nephritis and fibrosis characteristic of myeloma cast nephropathy
Kidney Biopsy
CASE STUDYbull A 35 year old African American woman was seen in the clinic for
chronic cough and dyspnea on exertion She gave history of vague symptoms of fatigue and weight loss of 20 Ibs over the last six months
bull List some differentialsbull TB sarcoid lupus thyroid problems PEbull What would you orderbull PPD cbc cmp UA TSH ANA pa and lat cxr
bull Her labs were significant for mildly elevated calcium level and a creatinine of 20 mgdL eGFR 37
bull She had 750 mg of proteinuriaday
bull PPD neg ANA neg TSH and other labs WNL
bull Assuming this is present more than 3 monthshelliphellipwhat is her ckd stage
bull G3b A3
bull What do we still need
CT scan of chest
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileAnterior_mediastinal_mass_thymomajpgCreative Commons License associated httpcreativecommonsorglicensesby20deeden
CXR ndash HILAR LYMPHADENOPATHY
WHATS NEEDED NEXT
bull Biopsy of hilar lymphadenopathy or renal biopsy
bull DX sarcoidosis
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileSarcoidosis_signs_and_symptomsjpgThis work is in the public domain in the United States because it is a work of the United States Federal Government under the terms of Title 17 Chapter 1 Section 105 of the US Code
NEWLY DX CKD
bull 1) urinalysis microscopy ultrasound proteincr ratio
bull If obstruction-treat
bull No obstruction
bull Hx critical (consider myeloma if high risk)
bull glomerular bleeding or albumin in urine
bull Yes workup for glomerular causes (ANArf hep B C upep spep ANCA complement C3 C4)
bull No sterile pyruria-consider interstitial nephritis
bull High risk renovascular disease Evaluate renovascular disease
Additional Online Resources for CKD LearningbullNational Kidney Foundation wwwkidneyorgbullUnited States Renal Data Service wwwusrdsorgbullCDCrsquos CKD Surveillance Project
httpnccdcdcgovckdbullNational Kidney Disease Education Program
(NKDEP) httpnkdepnihgov
BIBLIOGRAPHY
bull Afzali B amp Goldsmith D J (2016 June 29) Statins and chronic kidney disease (G C Curhan amp A M Sheridan Eds) Retrieved 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsstatins-and-chronic-kidney-disease
bull American Diabetes Association Standards of Medical Care in Diabetes (2017) Microvascular complications and foot care Diabetes Care 2017 (40) S88-S98
bull American Diabetes Association Standards of Medical Care in Diabetes (2017) Microvascular complications and foot care Diabetes Care 40 (suppl 1) S88-S98
bull Berns J S (2017 Mar 22) Treatment of anemia in nondialysis chronic kidney disease (T A Golper amp A M Sheridan Eds) Retrieved from UpToDate httpswww-uptodate-comproxywichitaeducontentstreatment-of-anemia-in-nondialysis-chronic-kidney-disease
bull Chan M Dall A T Fletcher K E Lu N amp Trivedi H (2007) Outcomes in patients with chronic kidney disease referred late to nephrologists a meta-analysis American Journal of Medicine 120(12) 1063-1070
bull Coresh J Selvin E amp Stevens L A (2007) Prevalence of chronic kidny disease in the United States JAMA 298(17) doi101001jama298172038
bull de Brito-Ashurst I Varagunam M Raftery M amp Yagoob M (2009) Bicarbonate supplementation slows progression of CKD and improves nutritional status Journal of American Society of Nephrology (20) 2075-2084
BIBLIOGRAPHY
bull Duncan L Heathcoat J Djurdjev O amp Levin A (2001) Screening for renal disease using serum creatinine who are we missing Nephrology Dialysis and Transplant 16(5) 1042-1046
bull Dunkler D Gao P Lee S F Heinz G Clase C M Tobe S Oberbauer R (2015 August 7) Risk prediction for early CKD in type 2 diabetes Retrieved from Clinical Journal of the American Society of Nephrology httpcjasnasnjournalsorgcontent1081371fullsid=61422554-a5f1-41ac-b696-dcd3b12bd268
bull Fatehi P amp Chi-yuan H (September 15 2016) Diagnostic approach to the patient with newly identified chronic kidney disease (G C Curhan amp A M Sheridan Eds) Retrieved May 7 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsdiagnostic-approach-to-the-patient-with-newly-identified-chronic-kidney-disease
bull Fink J e (2009) Chronic Kidney Disease as an Under-Recognized Threat to Patient Safety American journal of kidney diseases the official journal of the National Kidney Foundation 53(4) 681-688
bull Gaffo A L amp Saag K G (2008 Nov) Management of hyperuricemia and gout in CKD doihttpdxdoiorg101053jajkd200807035
bull Hebert L A amp Parikh S V (2014 June 18) Differential diagnosis and evaluation of glomerular disease (R J Glassock amp A Q Lam Eds) Retrieved May 7 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsdifferential-diagnosis-and-evaluation-of-glomerular-disease
bull Inker L Perrone R D Sterns R H amp Forman J P (2017 March 7) Assessment of kidney function Retrieved from UpToDate httpswww-uptodate-comproxywichitaeducontentsassessment-of-kidney-functionsource=search_resultampsearch=creatinineampselectedTitle=1~150
BIBLIOGRAPHY
bull James P A Ortiz E amp Et Al (2014) Evidence based guideline for the management of high blood pressure in adults (JNC) JAMA 311(5) 507-520
bull Kidney Disease Improving Global Outcomes (KDIGO) CKD Work Group (2013 January) KDIGO 2012 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease Retrieved from Kidney International Supplement httpwwwkidney-internationalorg
bull Kunz R Friedrich C Wolbers M amp Mann J F (2008) Meta-analysis effect of monotherapy and combination therapy with inhibitors of the renin angiotensin system on proteinuria in renal disease Annals of Internal Medicine 148(1) 30-48
bull Levey A Stevens L A Schmid C H Castro A F Feldman H I Kusek J W Coresh J (2009) A new equation to estimate glomerular filtration rate Annals of Internal Medicine 150(9) 604-612
bull Levin A Bakris G L Molitch M Smulders M M Williams L A amp Andress D L (2007 Jan) Prevalence of abnormal serum vitamin D PTH calcium and phosphorus in patients with chronic kidney disease results of the study to evaluate early kidney disease Kidney International 71(1) 31-38 Retrieved from PubMED
bull Mahajan A Simoni J Sheather S Broglio K Rajab M amp Wesson D (2010) Daily oral sodium bicarbonate preserves glomerular filtration rate by slowing its decline in early hypertensive nephropathy Kidney International (78_ 303-309
bull Mann J Schmieder R E amp McQueen M (2008) Renal outcomes with telmisartan ramipril or both in people at high vascular risk (the ONTARGET study) a multicentre randomised doubleblind ocntrolled trial Lancet 372(9638) 547-533
BIBLIOGRAPHY
bull Matovinović M S (2009) Pathophysiology and classification of kidney disease Retrieved from The Journal of the International Federation of Clinical Chemistry and Laboratory Medicine httpwwwifccorgifccfilesdocs20010902pdf
bull Moe S Drueke T Lameire N amp Eknoyan G (2007 Jan) Chronic kidney disease-mineral-bone disorder a new paradigmdoi101053jackd200610005
bull Murtagh F E Marsh J E Donohoe P Ekbal N J Sheerin N S amp Harris F E (2007 July) Dialysis or not A comparative survival study of patients over 75 years with chronic kidney disease stage 5 Retrieved from Nephrology Dialysis and Transplant 22(7) httpswwwncbinlmnihgovpubmed17412702
bull National Kidney Foundation (2002) KDOQI clinical practice guidelines for chronic kidney disease evaluation classification andstratification American Journal of Kidney Disease S1-S266
bull National Kidney Foundation (2014 November 5) Fact Sheets Retrieved from httpwwwkidneyorgnewsnewsroomfactsheetsFastFacts
bull Pal S (2012 June 2) Trends in chronic kidney disease Retrieved from US Pharmacist (37)6 httpswwwuspharmacistcomarticletrends-in-chronic-kidney-disease
bull Qunibi W amp Henrich W L (2017 Jan 19) Overview of chronic kidney disease-mineral and bone disorder (J Berns amp A M Sheridan Eds) Retrieved from UpToDate httpswww-uptodate-comoverview-of-chronic-kidney-disease-mineral-and-bone-disorder-ckd-mbd
bull Rosenberg M (2016 Feb 24) Overview of the management of chronic kidney disease in adults (G C Curhan amp A M Sheridan Eds) Retrieved from UpToDate UpToDate httpswww-uptodate-comproxywichitaeducontentsoverview-of-the-management-of-chronic-kidney-disease-in-adults
BIBLIOGRAPHY
bull Szczech L Stewart R C Hsu-Lin S DeLosky R J Astor B C Fox C H Vassalotti J A (2014) Primary care detection of chronic kidney disease in adults with type 2 diabetes The ADD-CKD Study (Awareness Detection and Drug Therapy in type 2 diabetes and chronic kidney disease PLOS doihttpsdoiorg101371journalpone0110535
bull USRDS (2016) Annual data report 2016 Epidemiology of kidney disease in the United States Retrieved from United States Renal Data System httpswwwusrdsorgadraspx
bull Vasudev B amp Vasudev M (2012) A model curriculum for residents rotating in nephrology MedEDPORTAL doihttpdoiorg1015766mep_2374-82658288
bull Wei L MacDonald T M Jennings C Sheng X amp Flynn R W (2013) Estimated GFR reporting is associated with decreased nonsteroidal anti-inflammatory drug prescribing and increased renal function Kidney International (84)1 174-178
chronic kidney disease in primary care
CKD as a Public Health Issue
Slide Number 3
Costs of CKD in 2013 dollarsUSRDS report
Steps to CKD Patient Care
Renal anatomy and physiology
Definition of Chronic Kidney Disease
CKD Risk Factors
Gaps in CKD Diagnosis
Slide Number 10
Steps to CKD Patient Care
creatinine
Glomerular filtration rate
Slide Number 14
Slide Number 15
Use These Equations Cautiously if at all in hellip
lab albumin creatinine ratio
The New CKD Categories
Steps to CKD Patient Care
Slide Number 20
Kidney Involvement in Systemic Diseases
Slide Number 22
Slide Number 23
DysmorphicRenal Hematuria
Slide Number 25
If you have albuminuria or hematuria-order the following labs
Prevalence of Abnormalities of Mineral Metabolism PTH in CKD
Managing CKD-MBD complications
CKD-MBD Testing
Anemia Becomes More Common as Kidney Function Declines
Detect and Manage CKD Complications
Complications-metabolic acidosis
Complications-vascular calcification
Hyperkalemia management
Hyperuricemia levels amp CKD
CKD monitoring levels 345
Slide Number 59
When to Refer to a Nephrologist
When to Refer
Steps to CKD Patient Care
Kidney transplantation
Starting Dialysis in the ElderlyhellipOr Not
Ckd management
Case 1
Slide Number 67
Lab results
Slide Number 69
Hypertensive nephropathy with proteinuria
Slide Number 71
Case 2
Slide Number 73
Management of CKD in Diabetes
Case 3
Case 3
Systemic Lupus Erythematosus (SLE)
SLE ndash Lupus Nephritis
Case 5
Case 5
Slide Number 81
Slide Number 82
Case study
Slide Number 84
CXR ndash Hilar Lymphadenopathy
Whats needed next
Slide Number 87
newly dx ckd
Slide Number 89
Bibliography
bibliography
bibliography
bibliography
bibliography
Stage 12
Stage 3
Stage 4
Stage 5
Hb le10 gdL
52
56
11
272
Hb gt10-le12 gdL
216
359
426
483
Hb le12 gdL
267
416
536
755
Stage 12
Stage 3
Stage 4
Stage 5
THE NEW CKD CATEGORIES
STEPS TO CKD PATIENT CARE
1 CKD definition and risks2 Assess GFR albuminuria3 Determine etiology- what is going on here4 Slow progression5 Assess for associated complications6 Discuss dialysistransplantation
(Pal 2012)
KIDNEY INVOLVEMENT IN SYSTEMIC DISEASES
Hypertension
DiabetesAmyloidosis
Sickle cell diseases
Immune complex GN
Illicit drugs ndash cocaine heroin
Cholesterol emboli
HIV
Allergic reactions- drugsinterstitial nephritis
Hemolytic Uremic syndrome
Lupus
Systemic vasculitis
Liver FailureCongestive heart Failure
Image retrieved on 05 October 2010 from httpenwikipediaorgwikiFileGray1129pngThis image is under the public domain and not copyrightable in the US as per Bridgeman Art Library v Corel Corp
(Vasudev amp Vasudev 2012)
New CKD
Obtain ultrasound UA
microscopy albumincr ratio
Ultrasound shows
obstruction
bull Yes Relieve obstruction
bull No Is there albuminuria or glomerular bleeding (eval for glomerulo-nephritis
Fatehi amp Chi-yuan 2016
If red cells have their typical shape and color this indicates extra glomerular hematuria
Examples kidney stone disease UTI cystitis bleeding from collecting duct ureters bladder or urethra
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileReactive_lymphJPGCreative Commons License associated httpcreativecommonsorglicensesby-sa30deeden
(Vasudev amp Vasudev 2012)
DYSMORPHICRENAL HEMATURIA
bull This hematuria is characterized by bull a great variation in the size of the cells and by a high
percentage of dysmorphocytosiscasts (gt20)
bull Hematuria is usually related to glomerular bleeding bull It is typically accompanied by variable levels of albumuniuria
(Vasudev amp Vasudev 2012)
Urinary Cast Formation
Urine Microscopy can be helpful in work up of chronic kidney disease
In GNrsquos the red blood cells leak from the glomerulus into the tubules As they traverse through the tubules they can form cylindrical casts calledRBC casts
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileRedbloodcellsjpgThis image is a work of the National Institutes of Health part of the United States Department of Health and Human Services As a work of the US federal government the image is in the public domain
(Vasudev amp Vasudev 2012)
IF YOU HAVE ALBUMINURIA OR HEMATURIA-ORDER THE FOLLOWING LABS
Tests of autoimmunity Hepatitis serologies gt40 years- paraproteinassessment
ANA Hepatitis B serology (HBsAG)
Serum protein electrophoresis (SPEP)
RFanti-ccp Hepatitis C serology(HCV antibody)
Urine protein electrophoresis (UPEP)
Complement C3 C4
ANCANational Kidney Disease Education Program 2014 NIH
UPTODATE LAB RECOMENDATIONS
bull Lab to order cbc cmp urine albumincr ratio urine microscopy
bull Nephrotic pattern (protein gt35gday) ANA anti DS DNA C3 and C4 antibodies HIV HBV HCV serumurine immunofixation (amyloidosis) free light chain analysis (light chain deposition disease)
bull Nephritic pattern (red cells white cells casts variable protein) C3 C4 ANA dsDNA antineutrophil cytoplasmic antibody (ANCA) titers a streptozyme test HBV and HCV serologies HIV and in some cases blood cultures anti-glomerular basement membrane (GBM) antibodies and cryoglobulins
bull Renal biopsy(Hebert amp Parikh 2014)
EVALUATION OF NEW CKDNO OBSTRUCTION
NO EVIDENCE OF GLOMERULAR BLEEDING
High risk for multmyeloma (gt40
no nsaids no contrast
SPEP UPEP with immunofixation serum free light
chains
Evaluation depends on UA
Sterile pyuria
Eval for interstitial nephritis
Normal urinalysis
High risk for renovascular
disease
Eval for renovascular
disease
Follow serum creatinine-does it
remain stable(Fatehi amp Chi-yuan 2016)
POSSIBLE INVESTIGATIONShellip
Acute interstitial nephritisbull Drugs are the most common cause of AIN
DIABETIC NEPHROPATHY 1 CAUSE OF CKDbull Clinical syndromebull Albuminuria gt30 mg 24 hrsbull Proteinuria gt500 mg24 hrsbull Hypertension developsbull Progressive increase in proteinuriabull Progressive decline in glomerular filtration rate
bull Chronic kidney disease should be attributed to diabetic nephropathies in most patients with diabetes if albuminuria and diabetic retinopathy are both present other causes of CKD should be entertained if diabetic retinopathy is absent (KDIGO 2007)
DIABETIC NEPHROPATHY MORTALITY
bull After 40 yrs of DM
bull 10 alive if proteinuria is present
bull 70 alive if proteinuria is absent
bull Heart Disease is 15 times higher risk in those with proteinuria
bull Proteinuria = death in this population
Dunkler et al 2015
GOALS OF CARE IN CKD GLUCOSE CONTROL
bull Target HbA1c ~70 (lt695 greatest chance of reducing albuminuria)bull Can be extended above 70 with comorbidities or limited life expectancy and
risk of hypoglycemiabull Risk of hypoglycemia increases as kidney function becomes impairedbull Declining kidney function may necessitate changes to diabetes medications and
bull Just having HTN can cause proteinuriabull Usually 1-2 gms of protein a daybull Treat them like a diabetic with ACEI or ARBS and tight blood
pressure controlbull JNC-8 goal lt14090 for ptrsquos with CKDbull National kidney foundation lt14090 if ckd and no proteinuria
lt13080 if proteinuria present
(James Ortiz amp Et Al 2014)
TREATING HYPERTENSIONPROTEINURIA ACEI ORARBbull Riskbenefit should be carefully assessed in the elderly and medically fragilebull Check labs after initiation
bull If less than 30 SCr increase continue and monitorbull If more than 30 SCr increase stop ACEi and evaluate for renal artery stenosis
bull Continue until contraindication arises no absolute eGFR cutoffbull Better proteinuria suppression with low Na diet and diureticsbull Avoid volume depletionbull Avoid ACEi and ARB in combination12
bull Risk of adverse events (impaired kidney function hyperkalemia)
(Kunz Friedrich Wolbers amp Mann 2008)(Mann Schmieder amp McQueen 2008)
bull In adults gt50 yrs statin when eGFR ge 60 mlmin173m2 statin or statinezetimibe combination when eGFR lt 60 mlmin173m2
bull In adults lt 50 yrs statin if history of known CAD MI DM strokebull Aspirin is indicated for secondary but not primary prevention
Kidney Disease Improving Global Outcomes (KDIGO) CKD Work Group Kidney Int Suppls 201331-150
STATINS-RENOPROTECTIVECONTROVERSY
bull HMG-CoA reductase inhibitors (statins) in high doses can cause proteinuria
bull Possibly associated with less inflammation endothelial dysfunction and scarring in the kidney because they also block inflammatory cytokines
bull Use statins for CV disease not to treat proteinuria
(Afzali and Goldsmith 2016)
MEDICINE CAUTION
bull Hold metformin when gfr lt35 mlmin
bull GFR lt50 mlmin should alert to check all doses of meds
bull No bisphosphanates lt35 mlmin
bull No NSAIDScox 2 inhibitors lt60 mlmin
bull Atenolol ndashrenal excretion
bull BACTRIM A lot of AKI
MEDICINE CAUTION
bull Lovenox-use subcut heparinbull Apixibanbull Dabigatranbull Rivaroxibanbull Lithiumbull GABAPENTIN (ckd 4 max 300mg qd ckd 5 max 300mg qod)
STEPS TO CKD PATIENT CARE
1 CKD definition and risks2 Assess GFR albuminuria3 Determine etiology4 Assess for evidence of progression5 Assess for associated complications6 Discuss dialysistransplantation
CKD-CVD-DIABETES LINK CKD IS A DISEASE MULTIPLIER
National kidney foundation 2014
KDIGO 2017
CKD-MINERAL BONE DISORDERS
bull As kidneys fail they
bull Stop activating calcitriol (the active form of Vit D)mdashcausing calcium imbalance
bull Do not remove phosphorus from bloodmdashleading to phosphorus retention
bull The extra phosphorus pulls calcium out of bones causing them to weaken
bull High phosphorus stimulates PTH release
bull These changes (plus others) cause the start of secondary hyperparathyroidism
bull Labs
bull eGFR
bull Calcium
bull Phos
bull Vit D
bull iPTH
(Qunibi amp Henrich 2017)
PREVALENCE OF ABNORMALITIES OF MINERAL METABOLISM PTH IN CKD
bull Progression of disease ndash declining eGFR increasing proteinuria
bull Degree of proteinuria nephrotic syndrome gt 05-10 gd on ACEi or ARB therapy
bull Etiology of CKD not certain
bull Need help with disease management
bull Indications for kidney biopsy
Rosenberg 2016
WHEN TO REFER
STEPS TO CKD PATIENT CARE
1 CKD definition and risks2 Assess GFR albuminuria3 Determine etiology4 Assess for evidence of progression5 Assess for associated complications6 Discuss dialysistransplantation
KIDNEY TRANSPLANTATION
bull Treatment of choice for ESRDbull Improves quality of lifebull Waiting list time varies-3-5 yearsbull 3 year survival rate after transplantation is 83-94bull Increased risk of cancer
STARTING DIALYSIS IN THE ELDERLYhellipOR NOT
bull Among patients gt 75 yrs with stage 5 CKD who chose to NOT start dialysisbull Overall more likely to die over next 1-2 years bull But if they had ischemic heart disease or other significant comorbidity NO
DIFFERENCE in survival
bull Active disease management and supportive care may be appropriate without starting dialysis in the ill elderly
bull Palliative care does not mean ldquono carerdquo
bull Must have end-of-life discussions
(Murtagh et al 2007)
CKD MANAGEMENTbull Diagnose cause and treat underlying conditionbull Stage per guidelinesbull Slow progression of kidney disease (ACE inhibitors)bull Monitor for complicationsmdashvolume overload hyperkalemia metabolic acidosis
hyperphosphatemia anorexia fatigue htn bone diseasebull Labs cmp cbc phos Vit D 25OH iPTH urine microscopy uric acid urine
proteincr ratio-frequency based off heat map Get sono at least oncebull Vaccinate influenza hep B pneumococcalbull Eval ASCVD risk-likely needs statinbull Possible dexa (donrsquot give bisphosphonates if GFRlt35 let specialist manage)bull Refer to nephrology when eGFR is lt30 (sometimes if higher risk-refer earlier)
CASE 1
bull 55 year old man with past medical history of headaches presents to your office for his first time visit to a PCP in over 30 years
bull He has no past history of being admitted to the hospital and he does not take any OTC medsNSAIDsherbal meds He has no history of ETOH abuse smoking or drug use
bull Vitals BP 180100 mmHg pulse 80 R 18
bull Exam No JVD S1S2 regular PMI shifted to the left no gallop no abdominal bruit pulses bilaterally equal and regular no leg edema
bull What would you order
bull EKG cbc cmp ua urine proteincr ratio lipid
LAB RESULTS
bull Labs reveal a creatinine of 22 mgdL eGFR 33 Urine shows no blood or casts Urineprotein ratio shows 1 gm protein24 hrs EKG shows LVH
bull Next step in workupbull Renal ultrasound 1st then SPEP UPEP with immunofixation serum free light chains
bull Additional labs neg Renal ultrasound shows that both kidneys are slightly reduced in size and are mildly echogenic with no mass or hydronephrosis
bull What is your diagnosis
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileMain_complications_of_persistent_high_blood_pressurepngCreative Commons License associated httpcreativecommonsorglicensesby-sa30
bull 3 months Howevermdashwe have evidence of structural abnormalities Could potentially stage at G3b A3 (red on the heat map)
bull Goal blood pressure
bull JNC 8 14090 NKF 13080
bull Additional lab needed for progression monitoring
bull Cbc renal panel phos Vit D iPTH uric acid urine micro (we already have the renal sono and urine proteincr ratio and lipid)
Selective renal angiography (left lower renal artery) after successful percutaneous balloon dilatation of the stenotic lesionFibromuscular dysplasia in an accessory renal artery causing renovascular hypertension
Secondary Hypertension
Images retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileRenal_FMD2jpg and httpcommonswikimediaorgwikiFileRenal_FMDjpgCreative Commons License associated httpcreativecommonsorglicensesby20deeden (both images)
CASE 2bull OS is a 64year old Hispanic female in for DM check She has had DM for 15+ years and is currently
taking metformin 1000mg bid Lisinopril 10mg a day atorvastatin 40mg a day Labs today showed the following
bull Hgba1c 86 cmp eGFR 50 lipid WNL proteincr ratio 650mg These results are similar to her last visit
bull Upon further hx-you find that she had a recent eye exam and has mild nonproliferaive retinopathy She does not have neuropathy or other ss
bull What further workup do you need
bull Renal sonogram urine micro iPTH vit D (25 OH) phos uric acid
bull Dx stage
bull G3a A3
bull What further treatment do you need
bull Improve glycemic control Increase Lisinopril to 20mg with a goal of 40mg Avoid NSAIDs or other nephrotoxic agents make sure meds are renally dosed monitor 3xyear nephro referral
MANAGEMENT OF CKD IN DIABETESeGFR Recommended
All patients
Yearly measurement of creatinine urinary albumin excretion potassium
45-60 Referral to a nephrologist if possibility for nondiabetickidney disease existsConsider dose adjustment of medicationsMonitor eGFR every 6 monthsMonitor electrolytes bicarbonate hemoglobin calcium phosphorus parathyroid hormone at least yearly
Assure vitamin D sufficiencyConsider bone density testingReferral for dietary counselling
American Diabetes Association Standards of Medical Care in Diabetes Microvascular complications and foot care Diabetes Care 2017 40 (Suppl 1) S88-S98
CASE 3
bull 19 year old African American woman presents to your clinic with complaints of fatigue joint pains a new rash on her face oral ulcer
bull On exam BP 15080 P 88 Afebrile 96 O2 sats on RAbull GEN No respiratory distress at restbull HEENT painless oral ulcer flat rash over malar eminences sparing the nasolabial fold pallor +bull Lungs CTAbull CVS S1S2 regularbull Abdomen soft NTbull Ext left elbow joint and bilateral wrist joints are swollen and tender
bull What would you orderbull CBC CMP ua urine microscopy (microalbumin or urine proteincr ratio) ANA esr RF anti-ccp uric acid TSH
CASE 3
bull Working dx fatigue oral ulcer joint pain
bull Basic Labs Na 135 K 55 Bicarb 18 BUN 50 Cr 35 eGFR 22 Ca 90 ANA + titer 1640
bull UA 3+ blood 3+ protein RBC casts +
bull Given these results what is the most likely diagnosis
bull What would you do
SYSTEMIC LUPUS ERYTHEMATOSUS (SLE)
bull SLE multisystemic disease Etiology unknown
bull Production of autoantibodies and immune complexes formation
bull There is renal involvement in the great majority of patients with SLE at some time of the evolution 66-90
SLE ndash LUPUS NEPHRITIS
bull Race SLE is more commonsevere in African americans than Caucasiansbull
bull Gender female-to-male ratio of 91
bull Age Most patients develop lupus nephritis early in their disease course SLE is more common among women in the third decade of life and lupus nephritis occurs in patients aged 20-40 years
bull Kidney Biopsy For staging lupus nephritis (Class 1-5)
CASE 5bull A 80 year old man who has not seen a PCP in many years
presents to your clinic for weakness for the past few months On further questioning he tells you that his bones also have been hurting lately and he has developed leg swelling in the past month or so
bull On exam bull BP 16090 P 88 Afebrilebull GEN Thin built manbull HEENT pallor presentbull Lungs clearbull CVS S1S2 regular no rub or gallopbull Abdomen soft NTbull Ext 2 + edema
CASE 5
bull Differentials
bull CHF MI Cancer arthritis
bull Labs
bull CBC CMP urine microscopy urine proteincr ratio ESR TSH EKG BNP pa and lat CXR
bull LABS Urine dipstick negative for protein or blood
bull Basic chem bull Na 136 (135-145) K 51 (35-55) Chloride 108 (96-106) Bicarb 25
Given this presentation and the labs (low anion gap and elevated calcium anemia kidney failure) what will you think of What will you order next
Serum and urine protein electrophoresis
Intratubular refractile casts with surrounding syncytial giant cell reaction with chronic tubulointerstitial nephritis and fibrosis characteristic of myeloma cast nephropathy
Kidney Biopsy
CASE STUDYbull A 35 year old African American woman was seen in the clinic for
chronic cough and dyspnea on exertion She gave history of vague symptoms of fatigue and weight loss of 20 Ibs over the last six months
bull List some differentialsbull TB sarcoid lupus thyroid problems PEbull What would you orderbull PPD cbc cmp UA TSH ANA pa and lat cxr
bull Her labs were significant for mildly elevated calcium level and a creatinine of 20 mgdL eGFR 37
bull She had 750 mg of proteinuriaday
bull PPD neg ANA neg TSH and other labs WNL
bull Assuming this is present more than 3 monthshelliphellipwhat is her ckd stage
bull G3b A3
bull What do we still need
CT scan of chest
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileAnterior_mediastinal_mass_thymomajpgCreative Commons License associated httpcreativecommonsorglicensesby20deeden
CXR ndash HILAR LYMPHADENOPATHY
WHATS NEEDED NEXT
bull Biopsy of hilar lymphadenopathy or renal biopsy
bull DX sarcoidosis
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileSarcoidosis_signs_and_symptomsjpgThis work is in the public domain in the United States because it is a work of the United States Federal Government under the terms of Title 17 Chapter 1 Section 105 of the US Code
NEWLY DX CKD
bull 1) urinalysis microscopy ultrasound proteincr ratio
bull If obstruction-treat
bull No obstruction
bull Hx critical (consider myeloma if high risk)
bull glomerular bleeding or albumin in urine
bull Yes workup for glomerular causes (ANArf hep B C upep spep ANCA complement C3 C4)
bull No sterile pyruria-consider interstitial nephritis
bull High risk renovascular disease Evaluate renovascular disease
Additional Online Resources for CKD LearningbullNational Kidney Foundation wwwkidneyorgbullUnited States Renal Data Service wwwusrdsorgbullCDCrsquos CKD Surveillance Project
httpnccdcdcgovckdbullNational Kidney Disease Education Program
(NKDEP) httpnkdepnihgov
BIBLIOGRAPHY
bull Afzali B amp Goldsmith D J (2016 June 29) Statins and chronic kidney disease (G C Curhan amp A M Sheridan Eds) Retrieved 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsstatins-and-chronic-kidney-disease
bull American Diabetes Association Standards of Medical Care in Diabetes (2017) Microvascular complications and foot care Diabetes Care 2017 (40) S88-S98
bull American Diabetes Association Standards of Medical Care in Diabetes (2017) Microvascular complications and foot care Diabetes Care 40 (suppl 1) S88-S98
bull Berns J S (2017 Mar 22) Treatment of anemia in nondialysis chronic kidney disease (T A Golper amp A M Sheridan Eds) Retrieved from UpToDate httpswww-uptodate-comproxywichitaeducontentstreatment-of-anemia-in-nondialysis-chronic-kidney-disease
bull Chan M Dall A T Fletcher K E Lu N amp Trivedi H (2007) Outcomes in patients with chronic kidney disease referred late to nephrologists a meta-analysis American Journal of Medicine 120(12) 1063-1070
bull Coresh J Selvin E amp Stevens L A (2007) Prevalence of chronic kidny disease in the United States JAMA 298(17) doi101001jama298172038
bull de Brito-Ashurst I Varagunam M Raftery M amp Yagoob M (2009) Bicarbonate supplementation slows progression of CKD and improves nutritional status Journal of American Society of Nephrology (20) 2075-2084
BIBLIOGRAPHY
bull Duncan L Heathcoat J Djurdjev O amp Levin A (2001) Screening for renal disease using serum creatinine who are we missing Nephrology Dialysis and Transplant 16(5) 1042-1046
bull Dunkler D Gao P Lee S F Heinz G Clase C M Tobe S Oberbauer R (2015 August 7) Risk prediction for early CKD in type 2 diabetes Retrieved from Clinical Journal of the American Society of Nephrology httpcjasnasnjournalsorgcontent1081371fullsid=61422554-a5f1-41ac-b696-dcd3b12bd268
bull Fatehi P amp Chi-yuan H (September 15 2016) Diagnostic approach to the patient with newly identified chronic kidney disease (G C Curhan amp A M Sheridan Eds) Retrieved May 7 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsdiagnostic-approach-to-the-patient-with-newly-identified-chronic-kidney-disease
bull Fink J e (2009) Chronic Kidney Disease as an Under-Recognized Threat to Patient Safety American journal of kidney diseases the official journal of the National Kidney Foundation 53(4) 681-688
bull Gaffo A L amp Saag K G (2008 Nov) Management of hyperuricemia and gout in CKD doihttpdxdoiorg101053jajkd200807035
bull Hebert L A amp Parikh S V (2014 June 18) Differential diagnosis and evaluation of glomerular disease (R J Glassock amp A Q Lam Eds) Retrieved May 7 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsdifferential-diagnosis-and-evaluation-of-glomerular-disease
bull Inker L Perrone R D Sterns R H amp Forman J P (2017 March 7) Assessment of kidney function Retrieved from UpToDate httpswww-uptodate-comproxywichitaeducontentsassessment-of-kidney-functionsource=search_resultampsearch=creatinineampselectedTitle=1~150
BIBLIOGRAPHY
bull James P A Ortiz E amp Et Al (2014) Evidence based guideline for the management of high blood pressure in adults (JNC) JAMA 311(5) 507-520
bull Kidney Disease Improving Global Outcomes (KDIGO) CKD Work Group (2013 January) KDIGO 2012 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease Retrieved from Kidney International Supplement httpwwwkidney-internationalorg
bull Kunz R Friedrich C Wolbers M amp Mann J F (2008) Meta-analysis effect of monotherapy and combination therapy with inhibitors of the renin angiotensin system on proteinuria in renal disease Annals of Internal Medicine 148(1) 30-48
bull Levey A Stevens L A Schmid C H Castro A F Feldman H I Kusek J W Coresh J (2009) A new equation to estimate glomerular filtration rate Annals of Internal Medicine 150(9) 604-612
bull Levin A Bakris G L Molitch M Smulders M M Williams L A amp Andress D L (2007 Jan) Prevalence of abnormal serum vitamin D PTH calcium and phosphorus in patients with chronic kidney disease results of the study to evaluate early kidney disease Kidney International 71(1) 31-38 Retrieved from PubMED
bull Mahajan A Simoni J Sheather S Broglio K Rajab M amp Wesson D (2010) Daily oral sodium bicarbonate preserves glomerular filtration rate by slowing its decline in early hypertensive nephropathy Kidney International (78_ 303-309
bull Mann J Schmieder R E amp McQueen M (2008) Renal outcomes with telmisartan ramipril or both in people at high vascular risk (the ONTARGET study) a multicentre randomised doubleblind ocntrolled trial Lancet 372(9638) 547-533
BIBLIOGRAPHY
bull Matovinović M S (2009) Pathophysiology and classification of kidney disease Retrieved from The Journal of the International Federation of Clinical Chemistry and Laboratory Medicine httpwwwifccorgifccfilesdocs20010902pdf
bull Moe S Drueke T Lameire N amp Eknoyan G (2007 Jan) Chronic kidney disease-mineral-bone disorder a new paradigmdoi101053jackd200610005
bull Murtagh F E Marsh J E Donohoe P Ekbal N J Sheerin N S amp Harris F E (2007 July) Dialysis or not A comparative survival study of patients over 75 years with chronic kidney disease stage 5 Retrieved from Nephrology Dialysis and Transplant 22(7) httpswwwncbinlmnihgovpubmed17412702
bull National Kidney Foundation (2002) KDOQI clinical practice guidelines for chronic kidney disease evaluation classification andstratification American Journal of Kidney Disease S1-S266
bull National Kidney Foundation (2014 November 5) Fact Sheets Retrieved from httpwwwkidneyorgnewsnewsroomfactsheetsFastFacts
bull Pal S (2012 June 2) Trends in chronic kidney disease Retrieved from US Pharmacist (37)6 httpswwwuspharmacistcomarticletrends-in-chronic-kidney-disease
bull Qunibi W amp Henrich W L (2017 Jan 19) Overview of chronic kidney disease-mineral and bone disorder (J Berns amp A M Sheridan Eds) Retrieved from UpToDate httpswww-uptodate-comoverview-of-chronic-kidney-disease-mineral-and-bone-disorder-ckd-mbd
bull Rosenberg M (2016 Feb 24) Overview of the management of chronic kidney disease in adults (G C Curhan amp A M Sheridan Eds) Retrieved from UpToDate UpToDate httpswww-uptodate-comproxywichitaeducontentsoverview-of-the-management-of-chronic-kidney-disease-in-adults
BIBLIOGRAPHY
bull Szczech L Stewart R C Hsu-Lin S DeLosky R J Astor B C Fox C H Vassalotti J A (2014) Primary care detection of chronic kidney disease in adults with type 2 diabetes The ADD-CKD Study (Awareness Detection and Drug Therapy in type 2 diabetes and chronic kidney disease PLOS doihttpsdoiorg101371journalpone0110535
bull USRDS (2016) Annual data report 2016 Epidemiology of kidney disease in the United States Retrieved from United States Renal Data System httpswwwusrdsorgadraspx
bull Vasudev B amp Vasudev M (2012) A model curriculum for residents rotating in nephrology MedEDPORTAL doihttpdoiorg1015766mep_2374-82658288
bull Wei L MacDonald T M Jennings C Sheng X amp Flynn R W (2013) Estimated GFR reporting is associated with decreased nonsteroidal anti-inflammatory drug prescribing and increased renal function Kidney International (84)1 174-178
chronic kidney disease in primary care
CKD as a Public Health Issue
Slide Number 3
Costs of CKD in 2013 dollarsUSRDS report
Steps to CKD Patient Care
Renal anatomy and physiology
Definition of Chronic Kidney Disease
CKD Risk Factors
Gaps in CKD Diagnosis
Slide Number 10
Steps to CKD Patient Care
creatinine
Glomerular filtration rate
Slide Number 14
Slide Number 15
Use These Equations Cautiously if at all in hellip
lab albumin creatinine ratio
The New CKD Categories
Steps to CKD Patient Care
Slide Number 20
Kidney Involvement in Systemic Diseases
Slide Number 22
Slide Number 23
DysmorphicRenal Hematuria
Slide Number 25
If you have albuminuria or hematuria-order the following labs
Prevalence of Abnormalities of Mineral Metabolism PTH in CKD
Managing CKD-MBD complications
CKD-MBD Testing
Anemia Becomes More Common as Kidney Function Declines
Detect and Manage CKD Complications
Complications-metabolic acidosis
Complications-vascular calcification
Hyperkalemia management
Hyperuricemia levels amp CKD
CKD monitoring levels 345
Slide Number 59
When to Refer to a Nephrologist
When to Refer
Steps to CKD Patient Care
Kidney transplantation
Starting Dialysis in the ElderlyhellipOr Not
Ckd management
Case 1
Slide Number 67
Lab results
Slide Number 69
Hypertensive nephropathy with proteinuria
Slide Number 71
Case 2
Slide Number 73
Management of CKD in Diabetes
Case 3
Case 3
Systemic Lupus Erythematosus (SLE)
SLE ndash Lupus Nephritis
Case 5
Case 5
Slide Number 81
Slide Number 82
Case study
Slide Number 84
CXR ndash Hilar Lymphadenopathy
Whats needed next
Slide Number 87
newly dx ckd
Slide Number 89
Bibliography
bibliography
bibliography
bibliography
bibliography
Stage 12
Stage 3
Stage 4
Stage 5
Hb le10 gdL
52
56
11
272
Hb gt10-le12 gdL
216
359
426
483
Hb le12 gdL
267
416
536
755
Stage 12
Stage 3
Stage 4
Stage 5
STEPS TO CKD PATIENT CARE
1 CKD definition and risks2 Assess GFR albuminuria3 Determine etiology- what is going on here4 Slow progression5 Assess for associated complications6 Discuss dialysistransplantation
(Pal 2012)
KIDNEY INVOLVEMENT IN SYSTEMIC DISEASES
Hypertension
DiabetesAmyloidosis
Sickle cell diseases
Immune complex GN
Illicit drugs ndash cocaine heroin
Cholesterol emboli
HIV
Allergic reactions- drugsinterstitial nephritis
Hemolytic Uremic syndrome
Lupus
Systemic vasculitis
Liver FailureCongestive heart Failure
Image retrieved on 05 October 2010 from httpenwikipediaorgwikiFileGray1129pngThis image is under the public domain and not copyrightable in the US as per Bridgeman Art Library v Corel Corp
(Vasudev amp Vasudev 2012)
New CKD
Obtain ultrasound UA
microscopy albumincr ratio
Ultrasound shows
obstruction
bull Yes Relieve obstruction
bull No Is there albuminuria or glomerular bleeding (eval for glomerulo-nephritis
Fatehi amp Chi-yuan 2016
If red cells have their typical shape and color this indicates extra glomerular hematuria
Examples kidney stone disease UTI cystitis bleeding from collecting duct ureters bladder or urethra
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileReactive_lymphJPGCreative Commons License associated httpcreativecommonsorglicensesby-sa30deeden
(Vasudev amp Vasudev 2012)
DYSMORPHICRENAL HEMATURIA
bull This hematuria is characterized by bull a great variation in the size of the cells and by a high
percentage of dysmorphocytosiscasts (gt20)
bull Hematuria is usually related to glomerular bleeding bull It is typically accompanied by variable levels of albumuniuria
(Vasudev amp Vasudev 2012)
Urinary Cast Formation
Urine Microscopy can be helpful in work up of chronic kidney disease
In GNrsquos the red blood cells leak from the glomerulus into the tubules As they traverse through the tubules they can form cylindrical casts calledRBC casts
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileRedbloodcellsjpgThis image is a work of the National Institutes of Health part of the United States Department of Health and Human Services As a work of the US federal government the image is in the public domain
(Vasudev amp Vasudev 2012)
IF YOU HAVE ALBUMINURIA OR HEMATURIA-ORDER THE FOLLOWING LABS
Tests of autoimmunity Hepatitis serologies gt40 years- paraproteinassessment
ANA Hepatitis B serology (HBsAG)
Serum protein electrophoresis (SPEP)
RFanti-ccp Hepatitis C serology(HCV antibody)
Urine protein electrophoresis (UPEP)
Complement C3 C4
ANCANational Kidney Disease Education Program 2014 NIH
UPTODATE LAB RECOMENDATIONS
bull Lab to order cbc cmp urine albumincr ratio urine microscopy
bull Nephrotic pattern (protein gt35gday) ANA anti DS DNA C3 and C4 antibodies HIV HBV HCV serumurine immunofixation (amyloidosis) free light chain analysis (light chain deposition disease)
bull Nephritic pattern (red cells white cells casts variable protein) C3 C4 ANA dsDNA antineutrophil cytoplasmic antibody (ANCA) titers a streptozyme test HBV and HCV serologies HIV and in some cases blood cultures anti-glomerular basement membrane (GBM) antibodies and cryoglobulins
bull Renal biopsy(Hebert amp Parikh 2014)
EVALUATION OF NEW CKDNO OBSTRUCTION
NO EVIDENCE OF GLOMERULAR BLEEDING
High risk for multmyeloma (gt40
no nsaids no contrast
SPEP UPEP with immunofixation serum free light
chains
Evaluation depends on UA
Sterile pyuria
Eval for interstitial nephritis
Normal urinalysis
High risk for renovascular
disease
Eval for renovascular
disease
Follow serum creatinine-does it
remain stable(Fatehi amp Chi-yuan 2016)
POSSIBLE INVESTIGATIONShellip
Acute interstitial nephritisbull Drugs are the most common cause of AIN
DIABETIC NEPHROPATHY 1 CAUSE OF CKDbull Clinical syndromebull Albuminuria gt30 mg 24 hrsbull Proteinuria gt500 mg24 hrsbull Hypertension developsbull Progressive increase in proteinuriabull Progressive decline in glomerular filtration rate
bull Chronic kidney disease should be attributed to diabetic nephropathies in most patients with diabetes if albuminuria and diabetic retinopathy are both present other causes of CKD should be entertained if diabetic retinopathy is absent (KDIGO 2007)
DIABETIC NEPHROPATHY MORTALITY
bull After 40 yrs of DM
bull 10 alive if proteinuria is present
bull 70 alive if proteinuria is absent
bull Heart Disease is 15 times higher risk in those with proteinuria
bull Proteinuria = death in this population
Dunkler et al 2015
GOALS OF CARE IN CKD GLUCOSE CONTROL
bull Target HbA1c ~70 (lt695 greatest chance of reducing albuminuria)bull Can be extended above 70 with comorbidities or limited life expectancy and
risk of hypoglycemiabull Risk of hypoglycemia increases as kidney function becomes impairedbull Declining kidney function may necessitate changes to diabetes medications and
bull Just having HTN can cause proteinuriabull Usually 1-2 gms of protein a daybull Treat them like a diabetic with ACEI or ARBS and tight blood
pressure controlbull JNC-8 goal lt14090 for ptrsquos with CKDbull National kidney foundation lt14090 if ckd and no proteinuria
lt13080 if proteinuria present
(James Ortiz amp Et Al 2014)
TREATING HYPERTENSIONPROTEINURIA ACEI ORARBbull Riskbenefit should be carefully assessed in the elderly and medically fragilebull Check labs after initiation
bull If less than 30 SCr increase continue and monitorbull If more than 30 SCr increase stop ACEi and evaluate for renal artery stenosis
bull Continue until contraindication arises no absolute eGFR cutoffbull Better proteinuria suppression with low Na diet and diureticsbull Avoid volume depletionbull Avoid ACEi and ARB in combination12
bull Risk of adverse events (impaired kidney function hyperkalemia)
(Kunz Friedrich Wolbers amp Mann 2008)(Mann Schmieder amp McQueen 2008)
bull In adults gt50 yrs statin when eGFR ge 60 mlmin173m2 statin or statinezetimibe combination when eGFR lt 60 mlmin173m2
bull In adults lt 50 yrs statin if history of known CAD MI DM strokebull Aspirin is indicated for secondary but not primary prevention
Kidney Disease Improving Global Outcomes (KDIGO) CKD Work Group Kidney Int Suppls 201331-150
STATINS-RENOPROTECTIVECONTROVERSY
bull HMG-CoA reductase inhibitors (statins) in high doses can cause proteinuria
bull Possibly associated with less inflammation endothelial dysfunction and scarring in the kidney because they also block inflammatory cytokines
bull Use statins for CV disease not to treat proteinuria
(Afzali and Goldsmith 2016)
MEDICINE CAUTION
bull Hold metformin when gfr lt35 mlmin
bull GFR lt50 mlmin should alert to check all doses of meds
bull No bisphosphanates lt35 mlmin
bull No NSAIDScox 2 inhibitors lt60 mlmin
bull Atenolol ndashrenal excretion
bull BACTRIM A lot of AKI
MEDICINE CAUTION
bull Lovenox-use subcut heparinbull Apixibanbull Dabigatranbull Rivaroxibanbull Lithiumbull GABAPENTIN (ckd 4 max 300mg qd ckd 5 max 300mg qod)
STEPS TO CKD PATIENT CARE
1 CKD definition and risks2 Assess GFR albuminuria3 Determine etiology4 Assess for evidence of progression5 Assess for associated complications6 Discuss dialysistransplantation
CKD-CVD-DIABETES LINK CKD IS A DISEASE MULTIPLIER
National kidney foundation 2014
KDIGO 2017
CKD-MINERAL BONE DISORDERS
bull As kidneys fail they
bull Stop activating calcitriol (the active form of Vit D)mdashcausing calcium imbalance
bull Do not remove phosphorus from bloodmdashleading to phosphorus retention
bull The extra phosphorus pulls calcium out of bones causing them to weaken
bull High phosphorus stimulates PTH release
bull These changes (plus others) cause the start of secondary hyperparathyroidism
bull Labs
bull eGFR
bull Calcium
bull Phos
bull Vit D
bull iPTH
(Qunibi amp Henrich 2017)
PREVALENCE OF ABNORMALITIES OF MINERAL METABOLISM PTH IN CKD
bull Progression of disease ndash declining eGFR increasing proteinuria
bull Degree of proteinuria nephrotic syndrome gt 05-10 gd on ACEi or ARB therapy
bull Etiology of CKD not certain
bull Need help with disease management
bull Indications for kidney biopsy
Rosenberg 2016
WHEN TO REFER
STEPS TO CKD PATIENT CARE
1 CKD definition and risks2 Assess GFR albuminuria3 Determine etiology4 Assess for evidence of progression5 Assess for associated complications6 Discuss dialysistransplantation
KIDNEY TRANSPLANTATION
bull Treatment of choice for ESRDbull Improves quality of lifebull Waiting list time varies-3-5 yearsbull 3 year survival rate after transplantation is 83-94bull Increased risk of cancer
STARTING DIALYSIS IN THE ELDERLYhellipOR NOT
bull Among patients gt 75 yrs with stage 5 CKD who chose to NOT start dialysisbull Overall more likely to die over next 1-2 years bull But if they had ischemic heart disease or other significant comorbidity NO
DIFFERENCE in survival
bull Active disease management and supportive care may be appropriate without starting dialysis in the ill elderly
bull Palliative care does not mean ldquono carerdquo
bull Must have end-of-life discussions
(Murtagh et al 2007)
CKD MANAGEMENTbull Diagnose cause and treat underlying conditionbull Stage per guidelinesbull Slow progression of kidney disease (ACE inhibitors)bull Monitor for complicationsmdashvolume overload hyperkalemia metabolic acidosis
hyperphosphatemia anorexia fatigue htn bone diseasebull Labs cmp cbc phos Vit D 25OH iPTH urine microscopy uric acid urine
proteincr ratio-frequency based off heat map Get sono at least oncebull Vaccinate influenza hep B pneumococcalbull Eval ASCVD risk-likely needs statinbull Possible dexa (donrsquot give bisphosphonates if GFRlt35 let specialist manage)bull Refer to nephrology when eGFR is lt30 (sometimes if higher risk-refer earlier)
CASE 1
bull 55 year old man with past medical history of headaches presents to your office for his first time visit to a PCP in over 30 years
bull He has no past history of being admitted to the hospital and he does not take any OTC medsNSAIDsherbal meds He has no history of ETOH abuse smoking or drug use
bull Vitals BP 180100 mmHg pulse 80 R 18
bull Exam No JVD S1S2 regular PMI shifted to the left no gallop no abdominal bruit pulses bilaterally equal and regular no leg edema
bull What would you order
bull EKG cbc cmp ua urine proteincr ratio lipid
LAB RESULTS
bull Labs reveal a creatinine of 22 mgdL eGFR 33 Urine shows no blood or casts Urineprotein ratio shows 1 gm protein24 hrs EKG shows LVH
bull Next step in workupbull Renal ultrasound 1st then SPEP UPEP with immunofixation serum free light chains
bull Additional labs neg Renal ultrasound shows that both kidneys are slightly reduced in size and are mildly echogenic with no mass or hydronephrosis
bull What is your diagnosis
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileMain_complications_of_persistent_high_blood_pressurepngCreative Commons License associated httpcreativecommonsorglicensesby-sa30
bull 3 months Howevermdashwe have evidence of structural abnormalities Could potentially stage at G3b A3 (red on the heat map)
bull Goal blood pressure
bull JNC 8 14090 NKF 13080
bull Additional lab needed for progression monitoring
bull Cbc renal panel phos Vit D iPTH uric acid urine micro (we already have the renal sono and urine proteincr ratio and lipid)
Selective renal angiography (left lower renal artery) after successful percutaneous balloon dilatation of the stenotic lesionFibromuscular dysplasia in an accessory renal artery causing renovascular hypertension
Secondary Hypertension
Images retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileRenal_FMD2jpg and httpcommonswikimediaorgwikiFileRenal_FMDjpgCreative Commons License associated httpcreativecommonsorglicensesby20deeden (both images)
CASE 2bull OS is a 64year old Hispanic female in for DM check She has had DM for 15+ years and is currently
taking metformin 1000mg bid Lisinopril 10mg a day atorvastatin 40mg a day Labs today showed the following
bull Hgba1c 86 cmp eGFR 50 lipid WNL proteincr ratio 650mg These results are similar to her last visit
bull Upon further hx-you find that she had a recent eye exam and has mild nonproliferaive retinopathy She does not have neuropathy or other ss
bull What further workup do you need
bull Renal sonogram urine micro iPTH vit D (25 OH) phos uric acid
bull Dx stage
bull G3a A3
bull What further treatment do you need
bull Improve glycemic control Increase Lisinopril to 20mg with a goal of 40mg Avoid NSAIDs or other nephrotoxic agents make sure meds are renally dosed monitor 3xyear nephro referral
MANAGEMENT OF CKD IN DIABETESeGFR Recommended
All patients
Yearly measurement of creatinine urinary albumin excretion potassium
45-60 Referral to a nephrologist if possibility for nondiabetickidney disease existsConsider dose adjustment of medicationsMonitor eGFR every 6 monthsMonitor electrolytes bicarbonate hemoglobin calcium phosphorus parathyroid hormone at least yearly
Assure vitamin D sufficiencyConsider bone density testingReferral for dietary counselling
American Diabetes Association Standards of Medical Care in Diabetes Microvascular complications and foot care Diabetes Care 2017 40 (Suppl 1) S88-S98
CASE 3
bull 19 year old African American woman presents to your clinic with complaints of fatigue joint pains a new rash on her face oral ulcer
bull On exam BP 15080 P 88 Afebrile 96 O2 sats on RAbull GEN No respiratory distress at restbull HEENT painless oral ulcer flat rash over malar eminences sparing the nasolabial fold pallor +bull Lungs CTAbull CVS S1S2 regularbull Abdomen soft NTbull Ext left elbow joint and bilateral wrist joints are swollen and tender
bull What would you orderbull CBC CMP ua urine microscopy (microalbumin or urine proteincr ratio) ANA esr RF anti-ccp uric acid TSH
CASE 3
bull Working dx fatigue oral ulcer joint pain
bull Basic Labs Na 135 K 55 Bicarb 18 BUN 50 Cr 35 eGFR 22 Ca 90 ANA + titer 1640
bull UA 3+ blood 3+ protein RBC casts +
bull Given these results what is the most likely diagnosis
bull What would you do
SYSTEMIC LUPUS ERYTHEMATOSUS (SLE)
bull SLE multisystemic disease Etiology unknown
bull Production of autoantibodies and immune complexes formation
bull There is renal involvement in the great majority of patients with SLE at some time of the evolution 66-90
SLE ndash LUPUS NEPHRITIS
bull Race SLE is more commonsevere in African americans than Caucasiansbull
bull Gender female-to-male ratio of 91
bull Age Most patients develop lupus nephritis early in their disease course SLE is more common among women in the third decade of life and lupus nephritis occurs in patients aged 20-40 years
bull Kidney Biopsy For staging lupus nephritis (Class 1-5)
CASE 5bull A 80 year old man who has not seen a PCP in many years
presents to your clinic for weakness for the past few months On further questioning he tells you that his bones also have been hurting lately and he has developed leg swelling in the past month or so
bull On exam bull BP 16090 P 88 Afebrilebull GEN Thin built manbull HEENT pallor presentbull Lungs clearbull CVS S1S2 regular no rub or gallopbull Abdomen soft NTbull Ext 2 + edema
CASE 5
bull Differentials
bull CHF MI Cancer arthritis
bull Labs
bull CBC CMP urine microscopy urine proteincr ratio ESR TSH EKG BNP pa and lat CXR
bull LABS Urine dipstick negative for protein or blood
bull Basic chem bull Na 136 (135-145) K 51 (35-55) Chloride 108 (96-106) Bicarb 25
Given this presentation and the labs (low anion gap and elevated calcium anemia kidney failure) what will you think of What will you order next
Serum and urine protein electrophoresis
Intratubular refractile casts with surrounding syncytial giant cell reaction with chronic tubulointerstitial nephritis and fibrosis characteristic of myeloma cast nephropathy
Kidney Biopsy
CASE STUDYbull A 35 year old African American woman was seen in the clinic for
chronic cough and dyspnea on exertion She gave history of vague symptoms of fatigue and weight loss of 20 Ibs over the last six months
bull List some differentialsbull TB sarcoid lupus thyroid problems PEbull What would you orderbull PPD cbc cmp UA TSH ANA pa and lat cxr
bull Her labs were significant for mildly elevated calcium level and a creatinine of 20 mgdL eGFR 37
bull She had 750 mg of proteinuriaday
bull PPD neg ANA neg TSH and other labs WNL
bull Assuming this is present more than 3 monthshelliphellipwhat is her ckd stage
bull G3b A3
bull What do we still need
CT scan of chest
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileAnterior_mediastinal_mass_thymomajpgCreative Commons License associated httpcreativecommonsorglicensesby20deeden
CXR ndash HILAR LYMPHADENOPATHY
WHATS NEEDED NEXT
bull Biopsy of hilar lymphadenopathy or renal biopsy
bull DX sarcoidosis
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileSarcoidosis_signs_and_symptomsjpgThis work is in the public domain in the United States because it is a work of the United States Federal Government under the terms of Title 17 Chapter 1 Section 105 of the US Code
NEWLY DX CKD
bull 1) urinalysis microscopy ultrasound proteincr ratio
bull If obstruction-treat
bull No obstruction
bull Hx critical (consider myeloma if high risk)
bull glomerular bleeding or albumin in urine
bull Yes workup for glomerular causes (ANArf hep B C upep spep ANCA complement C3 C4)
bull No sterile pyruria-consider interstitial nephritis
bull High risk renovascular disease Evaluate renovascular disease
Additional Online Resources for CKD LearningbullNational Kidney Foundation wwwkidneyorgbullUnited States Renal Data Service wwwusrdsorgbullCDCrsquos CKD Surveillance Project
httpnccdcdcgovckdbullNational Kidney Disease Education Program
(NKDEP) httpnkdepnihgov
BIBLIOGRAPHY
bull Afzali B amp Goldsmith D J (2016 June 29) Statins and chronic kidney disease (G C Curhan amp A M Sheridan Eds) Retrieved 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsstatins-and-chronic-kidney-disease
bull American Diabetes Association Standards of Medical Care in Diabetes (2017) Microvascular complications and foot care Diabetes Care 2017 (40) S88-S98
bull American Diabetes Association Standards of Medical Care in Diabetes (2017) Microvascular complications and foot care Diabetes Care 40 (suppl 1) S88-S98
bull Berns J S (2017 Mar 22) Treatment of anemia in nondialysis chronic kidney disease (T A Golper amp A M Sheridan Eds) Retrieved from UpToDate httpswww-uptodate-comproxywichitaeducontentstreatment-of-anemia-in-nondialysis-chronic-kidney-disease
bull Chan M Dall A T Fletcher K E Lu N amp Trivedi H (2007) Outcomes in patients with chronic kidney disease referred late to nephrologists a meta-analysis American Journal of Medicine 120(12) 1063-1070
bull Coresh J Selvin E amp Stevens L A (2007) Prevalence of chronic kidny disease in the United States JAMA 298(17) doi101001jama298172038
bull de Brito-Ashurst I Varagunam M Raftery M amp Yagoob M (2009) Bicarbonate supplementation slows progression of CKD and improves nutritional status Journal of American Society of Nephrology (20) 2075-2084
BIBLIOGRAPHY
bull Duncan L Heathcoat J Djurdjev O amp Levin A (2001) Screening for renal disease using serum creatinine who are we missing Nephrology Dialysis and Transplant 16(5) 1042-1046
bull Dunkler D Gao P Lee S F Heinz G Clase C M Tobe S Oberbauer R (2015 August 7) Risk prediction for early CKD in type 2 diabetes Retrieved from Clinical Journal of the American Society of Nephrology httpcjasnasnjournalsorgcontent1081371fullsid=61422554-a5f1-41ac-b696-dcd3b12bd268
bull Fatehi P amp Chi-yuan H (September 15 2016) Diagnostic approach to the patient with newly identified chronic kidney disease (G C Curhan amp A M Sheridan Eds) Retrieved May 7 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsdiagnostic-approach-to-the-patient-with-newly-identified-chronic-kidney-disease
bull Fink J e (2009) Chronic Kidney Disease as an Under-Recognized Threat to Patient Safety American journal of kidney diseases the official journal of the National Kidney Foundation 53(4) 681-688
bull Gaffo A L amp Saag K G (2008 Nov) Management of hyperuricemia and gout in CKD doihttpdxdoiorg101053jajkd200807035
bull Hebert L A amp Parikh S V (2014 June 18) Differential diagnosis and evaluation of glomerular disease (R J Glassock amp A Q Lam Eds) Retrieved May 7 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsdifferential-diagnosis-and-evaluation-of-glomerular-disease
bull Inker L Perrone R D Sterns R H amp Forman J P (2017 March 7) Assessment of kidney function Retrieved from UpToDate httpswww-uptodate-comproxywichitaeducontentsassessment-of-kidney-functionsource=search_resultampsearch=creatinineampselectedTitle=1~150
BIBLIOGRAPHY
bull James P A Ortiz E amp Et Al (2014) Evidence based guideline for the management of high blood pressure in adults (JNC) JAMA 311(5) 507-520
bull Kidney Disease Improving Global Outcomes (KDIGO) CKD Work Group (2013 January) KDIGO 2012 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease Retrieved from Kidney International Supplement httpwwwkidney-internationalorg
bull Kunz R Friedrich C Wolbers M amp Mann J F (2008) Meta-analysis effect of monotherapy and combination therapy with inhibitors of the renin angiotensin system on proteinuria in renal disease Annals of Internal Medicine 148(1) 30-48
bull Levey A Stevens L A Schmid C H Castro A F Feldman H I Kusek J W Coresh J (2009) A new equation to estimate glomerular filtration rate Annals of Internal Medicine 150(9) 604-612
bull Levin A Bakris G L Molitch M Smulders M M Williams L A amp Andress D L (2007 Jan) Prevalence of abnormal serum vitamin D PTH calcium and phosphorus in patients with chronic kidney disease results of the study to evaluate early kidney disease Kidney International 71(1) 31-38 Retrieved from PubMED
bull Mahajan A Simoni J Sheather S Broglio K Rajab M amp Wesson D (2010) Daily oral sodium bicarbonate preserves glomerular filtration rate by slowing its decline in early hypertensive nephropathy Kidney International (78_ 303-309
bull Mann J Schmieder R E amp McQueen M (2008) Renal outcomes with telmisartan ramipril or both in people at high vascular risk (the ONTARGET study) a multicentre randomised doubleblind ocntrolled trial Lancet 372(9638) 547-533
BIBLIOGRAPHY
bull Matovinović M S (2009) Pathophysiology and classification of kidney disease Retrieved from The Journal of the International Federation of Clinical Chemistry and Laboratory Medicine httpwwwifccorgifccfilesdocs20010902pdf
bull Moe S Drueke T Lameire N amp Eknoyan G (2007 Jan) Chronic kidney disease-mineral-bone disorder a new paradigmdoi101053jackd200610005
bull Murtagh F E Marsh J E Donohoe P Ekbal N J Sheerin N S amp Harris F E (2007 July) Dialysis or not A comparative survival study of patients over 75 years with chronic kidney disease stage 5 Retrieved from Nephrology Dialysis and Transplant 22(7) httpswwwncbinlmnihgovpubmed17412702
bull National Kidney Foundation (2002) KDOQI clinical practice guidelines for chronic kidney disease evaluation classification andstratification American Journal of Kidney Disease S1-S266
bull National Kidney Foundation (2014 November 5) Fact Sheets Retrieved from httpwwwkidneyorgnewsnewsroomfactsheetsFastFacts
bull Pal S (2012 June 2) Trends in chronic kidney disease Retrieved from US Pharmacist (37)6 httpswwwuspharmacistcomarticletrends-in-chronic-kidney-disease
bull Qunibi W amp Henrich W L (2017 Jan 19) Overview of chronic kidney disease-mineral and bone disorder (J Berns amp A M Sheridan Eds) Retrieved from UpToDate httpswww-uptodate-comoverview-of-chronic-kidney-disease-mineral-and-bone-disorder-ckd-mbd
bull Rosenberg M (2016 Feb 24) Overview of the management of chronic kidney disease in adults (G C Curhan amp A M Sheridan Eds) Retrieved from UpToDate UpToDate httpswww-uptodate-comproxywichitaeducontentsoverview-of-the-management-of-chronic-kidney-disease-in-adults
BIBLIOGRAPHY
bull Szczech L Stewart R C Hsu-Lin S DeLosky R J Astor B C Fox C H Vassalotti J A (2014) Primary care detection of chronic kidney disease in adults with type 2 diabetes The ADD-CKD Study (Awareness Detection and Drug Therapy in type 2 diabetes and chronic kidney disease PLOS doihttpsdoiorg101371journalpone0110535
bull USRDS (2016) Annual data report 2016 Epidemiology of kidney disease in the United States Retrieved from United States Renal Data System httpswwwusrdsorgadraspx
bull Vasudev B amp Vasudev M (2012) A model curriculum for residents rotating in nephrology MedEDPORTAL doihttpdoiorg1015766mep_2374-82658288
bull Wei L MacDonald T M Jennings C Sheng X amp Flynn R W (2013) Estimated GFR reporting is associated with decreased nonsteroidal anti-inflammatory drug prescribing and increased renal function Kidney International (84)1 174-178
chronic kidney disease in primary care
CKD as a Public Health Issue
Slide Number 3
Costs of CKD in 2013 dollarsUSRDS report
Steps to CKD Patient Care
Renal anatomy and physiology
Definition of Chronic Kidney Disease
CKD Risk Factors
Gaps in CKD Diagnosis
Slide Number 10
Steps to CKD Patient Care
creatinine
Glomerular filtration rate
Slide Number 14
Slide Number 15
Use These Equations Cautiously if at all in hellip
lab albumin creatinine ratio
The New CKD Categories
Steps to CKD Patient Care
Slide Number 20
Kidney Involvement in Systemic Diseases
Slide Number 22
Slide Number 23
DysmorphicRenal Hematuria
Slide Number 25
If you have albuminuria or hematuria-order the following labs
Prevalence of Abnormalities of Mineral Metabolism PTH in CKD
Managing CKD-MBD complications
CKD-MBD Testing
Anemia Becomes More Common as Kidney Function Declines
Detect and Manage CKD Complications
Complications-metabolic acidosis
Complications-vascular calcification
Hyperkalemia management
Hyperuricemia levels amp CKD
CKD monitoring levels 345
Slide Number 59
When to Refer to a Nephrologist
When to Refer
Steps to CKD Patient Care
Kidney transplantation
Starting Dialysis in the ElderlyhellipOr Not
Ckd management
Case 1
Slide Number 67
Lab results
Slide Number 69
Hypertensive nephropathy with proteinuria
Slide Number 71
Case 2
Slide Number 73
Management of CKD in Diabetes
Case 3
Case 3
Systemic Lupus Erythematosus (SLE)
SLE ndash Lupus Nephritis
Case 5
Case 5
Slide Number 81
Slide Number 82
Case study
Slide Number 84
CXR ndash Hilar Lymphadenopathy
Whats needed next
Slide Number 87
newly dx ckd
Slide Number 89
Bibliography
bibliography
bibliography
bibliography
bibliography
Stage 12
Stage 3
Stage 4
Stage 5
Hb le10 gdL
52
56
11
272
Hb gt10-le12 gdL
216
359
426
483
Hb le12 gdL
267
416
536
755
Stage 12
Stage 3
Stage 4
Stage 5
(Pal 2012)
KIDNEY INVOLVEMENT IN SYSTEMIC DISEASES
Hypertension
DiabetesAmyloidosis
Sickle cell diseases
Immune complex GN
Illicit drugs ndash cocaine heroin
Cholesterol emboli
HIV
Allergic reactions- drugsinterstitial nephritis
Hemolytic Uremic syndrome
Lupus
Systemic vasculitis
Liver FailureCongestive heart Failure
Image retrieved on 05 October 2010 from httpenwikipediaorgwikiFileGray1129pngThis image is under the public domain and not copyrightable in the US as per Bridgeman Art Library v Corel Corp
(Vasudev amp Vasudev 2012)
New CKD
Obtain ultrasound UA
microscopy albumincr ratio
Ultrasound shows
obstruction
bull Yes Relieve obstruction
bull No Is there albuminuria or glomerular bleeding (eval for glomerulo-nephritis
Fatehi amp Chi-yuan 2016
If red cells have their typical shape and color this indicates extra glomerular hematuria
Examples kidney stone disease UTI cystitis bleeding from collecting duct ureters bladder or urethra
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileReactive_lymphJPGCreative Commons License associated httpcreativecommonsorglicensesby-sa30deeden
(Vasudev amp Vasudev 2012)
DYSMORPHICRENAL HEMATURIA
bull This hematuria is characterized by bull a great variation in the size of the cells and by a high
percentage of dysmorphocytosiscasts (gt20)
bull Hematuria is usually related to glomerular bleeding bull It is typically accompanied by variable levels of albumuniuria
(Vasudev amp Vasudev 2012)
Urinary Cast Formation
Urine Microscopy can be helpful in work up of chronic kidney disease
In GNrsquos the red blood cells leak from the glomerulus into the tubules As they traverse through the tubules they can form cylindrical casts calledRBC casts
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileRedbloodcellsjpgThis image is a work of the National Institutes of Health part of the United States Department of Health and Human Services As a work of the US federal government the image is in the public domain
(Vasudev amp Vasudev 2012)
IF YOU HAVE ALBUMINURIA OR HEMATURIA-ORDER THE FOLLOWING LABS
Tests of autoimmunity Hepatitis serologies gt40 years- paraproteinassessment
ANA Hepatitis B serology (HBsAG)
Serum protein electrophoresis (SPEP)
RFanti-ccp Hepatitis C serology(HCV antibody)
Urine protein electrophoresis (UPEP)
Complement C3 C4
ANCANational Kidney Disease Education Program 2014 NIH
UPTODATE LAB RECOMENDATIONS
bull Lab to order cbc cmp urine albumincr ratio urine microscopy
bull Nephrotic pattern (protein gt35gday) ANA anti DS DNA C3 and C4 antibodies HIV HBV HCV serumurine immunofixation (amyloidosis) free light chain analysis (light chain deposition disease)
bull Nephritic pattern (red cells white cells casts variable protein) C3 C4 ANA dsDNA antineutrophil cytoplasmic antibody (ANCA) titers a streptozyme test HBV and HCV serologies HIV and in some cases blood cultures anti-glomerular basement membrane (GBM) antibodies and cryoglobulins
bull Renal biopsy(Hebert amp Parikh 2014)
EVALUATION OF NEW CKDNO OBSTRUCTION
NO EVIDENCE OF GLOMERULAR BLEEDING
High risk for multmyeloma (gt40
no nsaids no contrast
SPEP UPEP with immunofixation serum free light
chains
Evaluation depends on UA
Sterile pyuria
Eval for interstitial nephritis
Normal urinalysis
High risk for renovascular
disease
Eval for renovascular
disease
Follow serum creatinine-does it
remain stable(Fatehi amp Chi-yuan 2016)
POSSIBLE INVESTIGATIONShellip
Acute interstitial nephritisbull Drugs are the most common cause of AIN
DIABETIC NEPHROPATHY 1 CAUSE OF CKDbull Clinical syndromebull Albuminuria gt30 mg 24 hrsbull Proteinuria gt500 mg24 hrsbull Hypertension developsbull Progressive increase in proteinuriabull Progressive decline in glomerular filtration rate
bull Chronic kidney disease should be attributed to diabetic nephropathies in most patients with diabetes if albuminuria and diabetic retinopathy are both present other causes of CKD should be entertained if diabetic retinopathy is absent (KDIGO 2007)
DIABETIC NEPHROPATHY MORTALITY
bull After 40 yrs of DM
bull 10 alive if proteinuria is present
bull 70 alive if proteinuria is absent
bull Heart Disease is 15 times higher risk in those with proteinuria
bull Proteinuria = death in this population
Dunkler et al 2015
GOALS OF CARE IN CKD GLUCOSE CONTROL
bull Target HbA1c ~70 (lt695 greatest chance of reducing albuminuria)bull Can be extended above 70 with comorbidities or limited life expectancy and
risk of hypoglycemiabull Risk of hypoglycemia increases as kidney function becomes impairedbull Declining kidney function may necessitate changes to diabetes medications and
bull Just having HTN can cause proteinuriabull Usually 1-2 gms of protein a daybull Treat them like a diabetic with ACEI or ARBS and tight blood
pressure controlbull JNC-8 goal lt14090 for ptrsquos with CKDbull National kidney foundation lt14090 if ckd and no proteinuria
lt13080 if proteinuria present
(James Ortiz amp Et Al 2014)
TREATING HYPERTENSIONPROTEINURIA ACEI ORARBbull Riskbenefit should be carefully assessed in the elderly and medically fragilebull Check labs after initiation
bull If less than 30 SCr increase continue and monitorbull If more than 30 SCr increase stop ACEi and evaluate for renal artery stenosis
bull Continue until contraindication arises no absolute eGFR cutoffbull Better proteinuria suppression with low Na diet and diureticsbull Avoid volume depletionbull Avoid ACEi and ARB in combination12
bull Risk of adverse events (impaired kidney function hyperkalemia)
(Kunz Friedrich Wolbers amp Mann 2008)(Mann Schmieder amp McQueen 2008)
bull In adults gt50 yrs statin when eGFR ge 60 mlmin173m2 statin or statinezetimibe combination when eGFR lt 60 mlmin173m2
bull In adults lt 50 yrs statin if history of known CAD MI DM strokebull Aspirin is indicated for secondary but not primary prevention
Kidney Disease Improving Global Outcomes (KDIGO) CKD Work Group Kidney Int Suppls 201331-150
STATINS-RENOPROTECTIVECONTROVERSY
bull HMG-CoA reductase inhibitors (statins) in high doses can cause proteinuria
bull Possibly associated with less inflammation endothelial dysfunction and scarring in the kidney because they also block inflammatory cytokines
bull Use statins for CV disease not to treat proteinuria
(Afzali and Goldsmith 2016)
MEDICINE CAUTION
bull Hold metformin when gfr lt35 mlmin
bull GFR lt50 mlmin should alert to check all doses of meds
bull No bisphosphanates lt35 mlmin
bull No NSAIDScox 2 inhibitors lt60 mlmin
bull Atenolol ndashrenal excretion
bull BACTRIM A lot of AKI
MEDICINE CAUTION
bull Lovenox-use subcut heparinbull Apixibanbull Dabigatranbull Rivaroxibanbull Lithiumbull GABAPENTIN (ckd 4 max 300mg qd ckd 5 max 300mg qod)
STEPS TO CKD PATIENT CARE
1 CKD definition and risks2 Assess GFR albuminuria3 Determine etiology4 Assess for evidence of progression5 Assess for associated complications6 Discuss dialysistransplantation
CKD-CVD-DIABETES LINK CKD IS A DISEASE MULTIPLIER
National kidney foundation 2014
KDIGO 2017
CKD-MINERAL BONE DISORDERS
bull As kidneys fail they
bull Stop activating calcitriol (the active form of Vit D)mdashcausing calcium imbalance
bull Do not remove phosphorus from bloodmdashleading to phosphorus retention
bull The extra phosphorus pulls calcium out of bones causing them to weaken
bull High phosphorus stimulates PTH release
bull These changes (plus others) cause the start of secondary hyperparathyroidism
bull Labs
bull eGFR
bull Calcium
bull Phos
bull Vit D
bull iPTH
(Qunibi amp Henrich 2017)
PREVALENCE OF ABNORMALITIES OF MINERAL METABOLISM PTH IN CKD
bull Progression of disease ndash declining eGFR increasing proteinuria
bull Degree of proteinuria nephrotic syndrome gt 05-10 gd on ACEi or ARB therapy
bull Etiology of CKD not certain
bull Need help with disease management
bull Indications for kidney biopsy
Rosenberg 2016
WHEN TO REFER
STEPS TO CKD PATIENT CARE
1 CKD definition and risks2 Assess GFR albuminuria3 Determine etiology4 Assess for evidence of progression5 Assess for associated complications6 Discuss dialysistransplantation
KIDNEY TRANSPLANTATION
bull Treatment of choice for ESRDbull Improves quality of lifebull Waiting list time varies-3-5 yearsbull 3 year survival rate after transplantation is 83-94bull Increased risk of cancer
STARTING DIALYSIS IN THE ELDERLYhellipOR NOT
bull Among patients gt 75 yrs with stage 5 CKD who chose to NOT start dialysisbull Overall more likely to die over next 1-2 years bull But if they had ischemic heart disease or other significant comorbidity NO
DIFFERENCE in survival
bull Active disease management and supportive care may be appropriate without starting dialysis in the ill elderly
bull Palliative care does not mean ldquono carerdquo
bull Must have end-of-life discussions
(Murtagh et al 2007)
CKD MANAGEMENTbull Diagnose cause and treat underlying conditionbull Stage per guidelinesbull Slow progression of kidney disease (ACE inhibitors)bull Monitor for complicationsmdashvolume overload hyperkalemia metabolic acidosis
hyperphosphatemia anorexia fatigue htn bone diseasebull Labs cmp cbc phos Vit D 25OH iPTH urine microscopy uric acid urine
proteincr ratio-frequency based off heat map Get sono at least oncebull Vaccinate influenza hep B pneumococcalbull Eval ASCVD risk-likely needs statinbull Possible dexa (donrsquot give bisphosphonates if GFRlt35 let specialist manage)bull Refer to nephrology when eGFR is lt30 (sometimes if higher risk-refer earlier)
CASE 1
bull 55 year old man with past medical history of headaches presents to your office for his first time visit to a PCP in over 30 years
bull He has no past history of being admitted to the hospital and he does not take any OTC medsNSAIDsherbal meds He has no history of ETOH abuse smoking or drug use
bull Vitals BP 180100 mmHg pulse 80 R 18
bull Exam No JVD S1S2 regular PMI shifted to the left no gallop no abdominal bruit pulses bilaterally equal and regular no leg edema
bull What would you order
bull EKG cbc cmp ua urine proteincr ratio lipid
LAB RESULTS
bull Labs reveal a creatinine of 22 mgdL eGFR 33 Urine shows no blood or casts Urineprotein ratio shows 1 gm protein24 hrs EKG shows LVH
bull Next step in workupbull Renal ultrasound 1st then SPEP UPEP with immunofixation serum free light chains
bull Additional labs neg Renal ultrasound shows that both kidneys are slightly reduced in size and are mildly echogenic with no mass or hydronephrosis
bull What is your diagnosis
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileMain_complications_of_persistent_high_blood_pressurepngCreative Commons License associated httpcreativecommonsorglicensesby-sa30
bull 3 months Howevermdashwe have evidence of structural abnormalities Could potentially stage at G3b A3 (red on the heat map)
bull Goal blood pressure
bull JNC 8 14090 NKF 13080
bull Additional lab needed for progression monitoring
bull Cbc renal panel phos Vit D iPTH uric acid urine micro (we already have the renal sono and urine proteincr ratio and lipid)
Selective renal angiography (left lower renal artery) after successful percutaneous balloon dilatation of the stenotic lesionFibromuscular dysplasia in an accessory renal artery causing renovascular hypertension
Secondary Hypertension
Images retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileRenal_FMD2jpg and httpcommonswikimediaorgwikiFileRenal_FMDjpgCreative Commons License associated httpcreativecommonsorglicensesby20deeden (both images)
CASE 2bull OS is a 64year old Hispanic female in for DM check She has had DM for 15+ years and is currently
taking metformin 1000mg bid Lisinopril 10mg a day atorvastatin 40mg a day Labs today showed the following
bull Hgba1c 86 cmp eGFR 50 lipid WNL proteincr ratio 650mg These results are similar to her last visit
bull Upon further hx-you find that she had a recent eye exam and has mild nonproliferaive retinopathy She does not have neuropathy or other ss
bull What further workup do you need
bull Renal sonogram urine micro iPTH vit D (25 OH) phos uric acid
bull Dx stage
bull G3a A3
bull What further treatment do you need
bull Improve glycemic control Increase Lisinopril to 20mg with a goal of 40mg Avoid NSAIDs or other nephrotoxic agents make sure meds are renally dosed monitor 3xyear nephro referral
MANAGEMENT OF CKD IN DIABETESeGFR Recommended
All patients
Yearly measurement of creatinine urinary albumin excretion potassium
45-60 Referral to a nephrologist if possibility for nondiabetickidney disease existsConsider dose adjustment of medicationsMonitor eGFR every 6 monthsMonitor electrolytes bicarbonate hemoglobin calcium phosphorus parathyroid hormone at least yearly
Assure vitamin D sufficiencyConsider bone density testingReferral for dietary counselling
American Diabetes Association Standards of Medical Care in Diabetes Microvascular complications and foot care Diabetes Care 2017 40 (Suppl 1) S88-S98
CASE 3
bull 19 year old African American woman presents to your clinic with complaints of fatigue joint pains a new rash on her face oral ulcer
bull On exam BP 15080 P 88 Afebrile 96 O2 sats on RAbull GEN No respiratory distress at restbull HEENT painless oral ulcer flat rash over malar eminences sparing the nasolabial fold pallor +bull Lungs CTAbull CVS S1S2 regularbull Abdomen soft NTbull Ext left elbow joint and bilateral wrist joints are swollen and tender
bull What would you orderbull CBC CMP ua urine microscopy (microalbumin or urine proteincr ratio) ANA esr RF anti-ccp uric acid TSH
CASE 3
bull Working dx fatigue oral ulcer joint pain
bull Basic Labs Na 135 K 55 Bicarb 18 BUN 50 Cr 35 eGFR 22 Ca 90 ANA + titer 1640
bull UA 3+ blood 3+ protein RBC casts +
bull Given these results what is the most likely diagnosis
bull What would you do
SYSTEMIC LUPUS ERYTHEMATOSUS (SLE)
bull SLE multisystemic disease Etiology unknown
bull Production of autoantibodies and immune complexes formation
bull There is renal involvement in the great majority of patients with SLE at some time of the evolution 66-90
SLE ndash LUPUS NEPHRITIS
bull Race SLE is more commonsevere in African americans than Caucasiansbull
bull Gender female-to-male ratio of 91
bull Age Most patients develop lupus nephritis early in their disease course SLE is more common among women in the third decade of life and lupus nephritis occurs in patients aged 20-40 years
bull Kidney Biopsy For staging lupus nephritis (Class 1-5)
CASE 5bull A 80 year old man who has not seen a PCP in many years
presents to your clinic for weakness for the past few months On further questioning he tells you that his bones also have been hurting lately and he has developed leg swelling in the past month or so
bull On exam bull BP 16090 P 88 Afebrilebull GEN Thin built manbull HEENT pallor presentbull Lungs clearbull CVS S1S2 regular no rub or gallopbull Abdomen soft NTbull Ext 2 + edema
CASE 5
bull Differentials
bull CHF MI Cancer arthritis
bull Labs
bull CBC CMP urine microscopy urine proteincr ratio ESR TSH EKG BNP pa and lat CXR
bull LABS Urine dipstick negative for protein or blood
bull Basic chem bull Na 136 (135-145) K 51 (35-55) Chloride 108 (96-106) Bicarb 25
Given this presentation and the labs (low anion gap and elevated calcium anemia kidney failure) what will you think of What will you order next
Serum and urine protein electrophoresis
Intratubular refractile casts with surrounding syncytial giant cell reaction with chronic tubulointerstitial nephritis and fibrosis characteristic of myeloma cast nephropathy
Kidney Biopsy
CASE STUDYbull A 35 year old African American woman was seen in the clinic for
chronic cough and dyspnea on exertion She gave history of vague symptoms of fatigue and weight loss of 20 Ibs over the last six months
bull List some differentialsbull TB sarcoid lupus thyroid problems PEbull What would you orderbull PPD cbc cmp UA TSH ANA pa and lat cxr
bull Her labs were significant for mildly elevated calcium level and a creatinine of 20 mgdL eGFR 37
bull She had 750 mg of proteinuriaday
bull PPD neg ANA neg TSH and other labs WNL
bull Assuming this is present more than 3 monthshelliphellipwhat is her ckd stage
bull G3b A3
bull What do we still need
CT scan of chest
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileAnterior_mediastinal_mass_thymomajpgCreative Commons License associated httpcreativecommonsorglicensesby20deeden
CXR ndash HILAR LYMPHADENOPATHY
WHATS NEEDED NEXT
bull Biopsy of hilar lymphadenopathy or renal biopsy
bull DX sarcoidosis
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileSarcoidosis_signs_and_symptomsjpgThis work is in the public domain in the United States because it is a work of the United States Federal Government under the terms of Title 17 Chapter 1 Section 105 of the US Code
NEWLY DX CKD
bull 1) urinalysis microscopy ultrasound proteincr ratio
bull If obstruction-treat
bull No obstruction
bull Hx critical (consider myeloma if high risk)
bull glomerular bleeding or albumin in urine
bull Yes workup for glomerular causes (ANArf hep B C upep spep ANCA complement C3 C4)
bull No sterile pyruria-consider interstitial nephritis
bull High risk renovascular disease Evaluate renovascular disease
Additional Online Resources for CKD LearningbullNational Kidney Foundation wwwkidneyorgbullUnited States Renal Data Service wwwusrdsorgbullCDCrsquos CKD Surveillance Project
httpnccdcdcgovckdbullNational Kidney Disease Education Program
(NKDEP) httpnkdepnihgov
BIBLIOGRAPHY
bull Afzali B amp Goldsmith D J (2016 June 29) Statins and chronic kidney disease (G C Curhan amp A M Sheridan Eds) Retrieved 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsstatins-and-chronic-kidney-disease
bull American Diabetes Association Standards of Medical Care in Diabetes (2017) Microvascular complications and foot care Diabetes Care 2017 (40) S88-S98
bull American Diabetes Association Standards of Medical Care in Diabetes (2017) Microvascular complications and foot care Diabetes Care 40 (suppl 1) S88-S98
bull Berns J S (2017 Mar 22) Treatment of anemia in nondialysis chronic kidney disease (T A Golper amp A M Sheridan Eds) Retrieved from UpToDate httpswww-uptodate-comproxywichitaeducontentstreatment-of-anemia-in-nondialysis-chronic-kidney-disease
bull Chan M Dall A T Fletcher K E Lu N amp Trivedi H (2007) Outcomes in patients with chronic kidney disease referred late to nephrologists a meta-analysis American Journal of Medicine 120(12) 1063-1070
bull Coresh J Selvin E amp Stevens L A (2007) Prevalence of chronic kidny disease in the United States JAMA 298(17) doi101001jama298172038
bull de Brito-Ashurst I Varagunam M Raftery M amp Yagoob M (2009) Bicarbonate supplementation slows progression of CKD and improves nutritional status Journal of American Society of Nephrology (20) 2075-2084
BIBLIOGRAPHY
bull Duncan L Heathcoat J Djurdjev O amp Levin A (2001) Screening for renal disease using serum creatinine who are we missing Nephrology Dialysis and Transplant 16(5) 1042-1046
bull Dunkler D Gao P Lee S F Heinz G Clase C M Tobe S Oberbauer R (2015 August 7) Risk prediction for early CKD in type 2 diabetes Retrieved from Clinical Journal of the American Society of Nephrology httpcjasnasnjournalsorgcontent1081371fullsid=61422554-a5f1-41ac-b696-dcd3b12bd268
bull Fatehi P amp Chi-yuan H (September 15 2016) Diagnostic approach to the patient with newly identified chronic kidney disease (G C Curhan amp A M Sheridan Eds) Retrieved May 7 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsdiagnostic-approach-to-the-patient-with-newly-identified-chronic-kidney-disease
bull Fink J e (2009) Chronic Kidney Disease as an Under-Recognized Threat to Patient Safety American journal of kidney diseases the official journal of the National Kidney Foundation 53(4) 681-688
bull Gaffo A L amp Saag K G (2008 Nov) Management of hyperuricemia and gout in CKD doihttpdxdoiorg101053jajkd200807035
bull Hebert L A amp Parikh S V (2014 June 18) Differential diagnosis and evaluation of glomerular disease (R J Glassock amp A Q Lam Eds) Retrieved May 7 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsdifferential-diagnosis-and-evaluation-of-glomerular-disease
bull Inker L Perrone R D Sterns R H amp Forman J P (2017 March 7) Assessment of kidney function Retrieved from UpToDate httpswww-uptodate-comproxywichitaeducontentsassessment-of-kidney-functionsource=search_resultampsearch=creatinineampselectedTitle=1~150
BIBLIOGRAPHY
bull James P A Ortiz E amp Et Al (2014) Evidence based guideline for the management of high blood pressure in adults (JNC) JAMA 311(5) 507-520
bull Kidney Disease Improving Global Outcomes (KDIGO) CKD Work Group (2013 January) KDIGO 2012 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease Retrieved from Kidney International Supplement httpwwwkidney-internationalorg
bull Kunz R Friedrich C Wolbers M amp Mann J F (2008) Meta-analysis effect of monotherapy and combination therapy with inhibitors of the renin angiotensin system on proteinuria in renal disease Annals of Internal Medicine 148(1) 30-48
bull Levey A Stevens L A Schmid C H Castro A F Feldman H I Kusek J W Coresh J (2009) A new equation to estimate glomerular filtration rate Annals of Internal Medicine 150(9) 604-612
bull Levin A Bakris G L Molitch M Smulders M M Williams L A amp Andress D L (2007 Jan) Prevalence of abnormal serum vitamin D PTH calcium and phosphorus in patients with chronic kidney disease results of the study to evaluate early kidney disease Kidney International 71(1) 31-38 Retrieved from PubMED
bull Mahajan A Simoni J Sheather S Broglio K Rajab M amp Wesson D (2010) Daily oral sodium bicarbonate preserves glomerular filtration rate by slowing its decline in early hypertensive nephropathy Kidney International (78_ 303-309
bull Mann J Schmieder R E amp McQueen M (2008) Renal outcomes with telmisartan ramipril or both in people at high vascular risk (the ONTARGET study) a multicentre randomised doubleblind ocntrolled trial Lancet 372(9638) 547-533
BIBLIOGRAPHY
bull Matovinović M S (2009) Pathophysiology and classification of kidney disease Retrieved from The Journal of the International Federation of Clinical Chemistry and Laboratory Medicine httpwwwifccorgifccfilesdocs20010902pdf
bull Moe S Drueke T Lameire N amp Eknoyan G (2007 Jan) Chronic kidney disease-mineral-bone disorder a new paradigmdoi101053jackd200610005
bull Murtagh F E Marsh J E Donohoe P Ekbal N J Sheerin N S amp Harris F E (2007 July) Dialysis or not A comparative survival study of patients over 75 years with chronic kidney disease stage 5 Retrieved from Nephrology Dialysis and Transplant 22(7) httpswwwncbinlmnihgovpubmed17412702
bull National Kidney Foundation (2002) KDOQI clinical practice guidelines for chronic kidney disease evaluation classification andstratification American Journal of Kidney Disease S1-S266
bull National Kidney Foundation (2014 November 5) Fact Sheets Retrieved from httpwwwkidneyorgnewsnewsroomfactsheetsFastFacts
bull Pal S (2012 June 2) Trends in chronic kidney disease Retrieved from US Pharmacist (37)6 httpswwwuspharmacistcomarticletrends-in-chronic-kidney-disease
bull Qunibi W amp Henrich W L (2017 Jan 19) Overview of chronic kidney disease-mineral and bone disorder (J Berns amp A M Sheridan Eds) Retrieved from UpToDate httpswww-uptodate-comoverview-of-chronic-kidney-disease-mineral-and-bone-disorder-ckd-mbd
bull Rosenberg M (2016 Feb 24) Overview of the management of chronic kidney disease in adults (G C Curhan amp A M Sheridan Eds) Retrieved from UpToDate UpToDate httpswww-uptodate-comproxywichitaeducontentsoverview-of-the-management-of-chronic-kidney-disease-in-adults
BIBLIOGRAPHY
bull Szczech L Stewart R C Hsu-Lin S DeLosky R J Astor B C Fox C H Vassalotti J A (2014) Primary care detection of chronic kidney disease in adults with type 2 diabetes The ADD-CKD Study (Awareness Detection and Drug Therapy in type 2 diabetes and chronic kidney disease PLOS doihttpsdoiorg101371journalpone0110535
bull USRDS (2016) Annual data report 2016 Epidemiology of kidney disease in the United States Retrieved from United States Renal Data System httpswwwusrdsorgadraspx
bull Vasudev B amp Vasudev M (2012) A model curriculum for residents rotating in nephrology MedEDPORTAL doihttpdoiorg1015766mep_2374-82658288
bull Wei L MacDonald T M Jennings C Sheng X amp Flynn R W (2013) Estimated GFR reporting is associated with decreased nonsteroidal anti-inflammatory drug prescribing and increased renal function Kidney International (84)1 174-178
chronic kidney disease in primary care
CKD as a Public Health Issue
Slide Number 3
Costs of CKD in 2013 dollarsUSRDS report
Steps to CKD Patient Care
Renal anatomy and physiology
Definition of Chronic Kidney Disease
CKD Risk Factors
Gaps in CKD Diagnosis
Slide Number 10
Steps to CKD Patient Care
creatinine
Glomerular filtration rate
Slide Number 14
Slide Number 15
Use These Equations Cautiously if at all in hellip
lab albumin creatinine ratio
The New CKD Categories
Steps to CKD Patient Care
Slide Number 20
Kidney Involvement in Systemic Diseases
Slide Number 22
Slide Number 23
DysmorphicRenal Hematuria
Slide Number 25
If you have albuminuria or hematuria-order the following labs
Prevalence of Abnormalities of Mineral Metabolism PTH in CKD
Managing CKD-MBD complications
CKD-MBD Testing
Anemia Becomes More Common as Kidney Function Declines
Detect and Manage CKD Complications
Complications-metabolic acidosis
Complications-vascular calcification
Hyperkalemia management
Hyperuricemia levels amp CKD
CKD monitoring levels 345
Slide Number 59
When to Refer to a Nephrologist
When to Refer
Steps to CKD Patient Care
Kidney transplantation
Starting Dialysis in the ElderlyhellipOr Not
Ckd management
Case 1
Slide Number 67
Lab results
Slide Number 69
Hypertensive nephropathy with proteinuria
Slide Number 71
Case 2
Slide Number 73
Management of CKD in Diabetes
Case 3
Case 3
Systemic Lupus Erythematosus (SLE)
SLE ndash Lupus Nephritis
Case 5
Case 5
Slide Number 81
Slide Number 82
Case study
Slide Number 84
CXR ndash Hilar Lymphadenopathy
Whats needed next
Slide Number 87
newly dx ckd
Slide Number 89
Bibliography
bibliography
bibliography
bibliography
bibliography
Stage 12
Stage 3
Stage 4
Stage 5
Hb le10 gdL
52
56
11
272
Hb gt10-le12 gdL
216
359
426
483
Hb le12 gdL
267
416
536
755
Stage 12
Stage 3
Stage 4
Stage 5
KIDNEY INVOLVEMENT IN SYSTEMIC DISEASES
Hypertension
DiabetesAmyloidosis
Sickle cell diseases
Immune complex GN
Illicit drugs ndash cocaine heroin
Cholesterol emboli
HIV
Allergic reactions- drugsinterstitial nephritis
Hemolytic Uremic syndrome
Lupus
Systemic vasculitis
Liver FailureCongestive heart Failure
Image retrieved on 05 October 2010 from httpenwikipediaorgwikiFileGray1129pngThis image is under the public domain and not copyrightable in the US as per Bridgeman Art Library v Corel Corp
(Vasudev amp Vasudev 2012)
New CKD
Obtain ultrasound UA
microscopy albumincr ratio
Ultrasound shows
obstruction
bull Yes Relieve obstruction
bull No Is there albuminuria or glomerular bleeding (eval for glomerulo-nephritis
Fatehi amp Chi-yuan 2016
If red cells have their typical shape and color this indicates extra glomerular hematuria
Examples kidney stone disease UTI cystitis bleeding from collecting duct ureters bladder or urethra
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileReactive_lymphJPGCreative Commons License associated httpcreativecommonsorglicensesby-sa30deeden
(Vasudev amp Vasudev 2012)
DYSMORPHICRENAL HEMATURIA
bull This hematuria is characterized by bull a great variation in the size of the cells and by a high
percentage of dysmorphocytosiscasts (gt20)
bull Hematuria is usually related to glomerular bleeding bull It is typically accompanied by variable levels of albumuniuria
(Vasudev amp Vasudev 2012)
Urinary Cast Formation
Urine Microscopy can be helpful in work up of chronic kidney disease
In GNrsquos the red blood cells leak from the glomerulus into the tubules As they traverse through the tubules they can form cylindrical casts calledRBC casts
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileRedbloodcellsjpgThis image is a work of the National Institutes of Health part of the United States Department of Health and Human Services As a work of the US federal government the image is in the public domain
(Vasudev amp Vasudev 2012)
IF YOU HAVE ALBUMINURIA OR HEMATURIA-ORDER THE FOLLOWING LABS
Tests of autoimmunity Hepatitis serologies gt40 years- paraproteinassessment
ANA Hepatitis B serology (HBsAG)
Serum protein electrophoresis (SPEP)
RFanti-ccp Hepatitis C serology(HCV antibody)
Urine protein electrophoresis (UPEP)
Complement C3 C4
ANCANational Kidney Disease Education Program 2014 NIH
UPTODATE LAB RECOMENDATIONS
bull Lab to order cbc cmp urine albumincr ratio urine microscopy
bull Nephrotic pattern (protein gt35gday) ANA anti DS DNA C3 and C4 antibodies HIV HBV HCV serumurine immunofixation (amyloidosis) free light chain analysis (light chain deposition disease)
bull Nephritic pattern (red cells white cells casts variable protein) C3 C4 ANA dsDNA antineutrophil cytoplasmic antibody (ANCA) titers a streptozyme test HBV and HCV serologies HIV and in some cases blood cultures anti-glomerular basement membrane (GBM) antibodies and cryoglobulins
bull Renal biopsy(Hebert amp Parikh 2014)
EVALUATION OF NEW CKDNO OBSTRUCTION
NO EVIDENCE OF GLOMERULAR BLEEDING
High risk for multmyeloma (gt40
no nsaids no contrast
SPEP UPEP with immunofixation serum free light
chains
Evaluation depends on UA
Sterile pyuria
Eval for interstitial nephritis
Normal urinalysis
High risk for renovascular
disease
Eval for renovascular
disease
Follow serum creatinine-does it
remain stable(Fatehi amp Chi-yuan 2016)
POSSIBLE INVESTIGATIONShellip
Acute interstitial nephritisbull Drugs are the most common cause of AIN
DIABETIC NEPHROPATHY 1 CAUSE OF CKDbull Clinical syndromebull Albuminuria gt30 mg 24 hrsbull Proteinuria gt500 mg24 hrsbull Hypertension developsbull Progressive increase in proteinuriabull Progressive decline in glomerular filtration rate
bull Chronic kidney disease should be attributed to diabetic nephropathies in most patients with diabetes if albuminuria and diabetic retinopathy are both present other causes of CKD should be entertained if diabetic retinopathy is absent (KDIGO 2007)
DIABETIC NEPHROPATHY MORTALITY
bull After 40 yrs of DM
bull 10 alive if proteinuria is present
bull 70 alive if proteinuria is absent
bull Heart Disease is 15 times higher risk in those with proteinuria
bull Proteinuria = death in this population
Dunkler et al 2015
GOALS OF CARE IN CKD GLUCOSE CONTROL
bull Target HbA1c ~70 (lt695 greatest chance of reducing albuminuria)bull Can be extended above 70 with comorbidities or limited life expectancy and
risk of hypoglycemiabull Risk of hypoglycemia increases as kidney function becomes impairedbull Declining kidney function may necessitate changes to diabetes medications and
bull Just having HTN can cause proteinuriabull Usually 1-2 gms of protein a daybull Treat them like a diabetic with ACEI or ARBS and tight blood
pressure controlbull JNC-8 goal lt14090 for ptrsquos with CKDbull National kidney foundation lt14090 if ckd and no proteinuria
lt13080 if proteinuria present
(James Ortiz amp Et Al 2014)
TREATING HYPERTENSIONPROTEINURIA ACEI ORARBbull Riskbenefit should be carefully assessed in the elderly and medically fragilebull Check labs after initiation
bull If less than 30 SCr increase continue and monitorbull If more than 30 SCr increase stop ACEi and evaluate for renal artery stenosis
bull Continue until contraindication arises no absolute eGFR cutoffbull Better proteinuria suppression with low Na diet and diureticsbull Avoid volume depletionbull Avoid ACEi and ARB in combination12
bull Risk of adverse events (impaired kidney function hyperkalemia)
(Kunz Friedrich Wolbers amp Mann 2008)(Mann Schmieder amp McQueen 2008)
bull In adults gt50 yrs statin when eGFR ge 60 mlmin173m2 statin or statinezetimibe combination when eGFR lt 60 mlmin173m2
bull In adults lt 50 yrs statin if history of known CAD MI DM strokebull Aspirin is indicated for secondary but not primary prevention
Kidney Disease Improving Global Outcomes (KDIGO) CKD Work Group Kidney Int Suppls 201331-150
STATINS-RENOPROTECTIVECONTROVERSY
bull HMG-CoA reductase inhibitors (statins) in high doses can cause proteinuria
bull Possibly associated with less inflammation endothelial dysfunction and scarring in the kidney because they also block inflammatory cytokines
bull Use statins for CV disease not to treat proteinuria
(Afzali and Goldsmith 2016)
MEDICINE CAUTION
bull Hold metformin when gfr lt35 mlmin
bull GFR lt50 mlmin should alert to check all doses of meds
bull No bisphosphanates lt35 mlmin
bull No NSAIDScox 2 inhibitors lt60 mlmin
bull Atenolol ndashrenal excretion
bull BACTRIM A lot of AKI
MEDICINE CAUTION
bull Lovenox-use subcut heparinbull Apixibanbull Dabigatranbull Rivaroxibanbull Lithiumbull GABAPENTIN (ckd 4 max 300mg qd ckd 5 max 300mg qod)
STEPS TO CKD PATIENT CARE
1 CKD definition and risks2 Assess GFR albuminuria3 Determine etiology4 Assess for evidence of progression5 Assess for associated complications6 Discuss dialysistransplantation
CKD-CVD-DIABETES LINK CKD IS A DISEASE MULTIPLIER
National kidney foundation 2014
KDIGO 2017
CKD-MINERAL BONE DISORDERS
bull As kidneys fail they
bull Stop activating calcitriol (the active form of Vit D)mdashcausing calcium imbalance
bull Do not remove phosphorus from bloodmdashleading to phosphorus retention
bull The extra phosphorus pulls calcium out of bones causing them to weaken
bull High phosphorus stimulates PTH release
bull These changes (plus others) cause the start of secondary hyperparathyroidism
bull Labs
bull eGFR
bull Calcium
bull Phos
bull Vit D
bull iPTH
(Qunibi amp Henrich 2017)
PREVALENCE OF ABNORMALITIES OF MINERAL METABOLISM PTH IN CKD
bull Progression of disease ndash declining eGFR increasing proteinuria
bull Degree of proteinuria nephrotic syndrome gt 05-10 gd on ACEi or ARB therapy
bull Etiology of CKD not certain
bull Need help with disease management
bull Indications for kidney biopsy
Rosenberg 2016
WHEN TO REFER
STEPS TO CKD PATIENT CARE
1 CKD definition and risks2 Assess GFR albuminuria3 Determine etiology4 Assess for evidence of progression5 Assess for associated complications6 Discuss dialysistransplantation
KIDNEY TRANSPLANTATION
bull Treatment of choice for ESRDbull Improves quality of lifebull Waiting list time varies-3-5 yearsbull 3 year survival rate after transplantation is 83-94bull Increased risk of cancer
STARTING DIALYSIS IN THE ELDERLYhellipOR NOT
bull Among patients gt 75 yrs with stage 5 CKD who chose to NOT start dialysisbull Overall more likely to die over next 1-2 years bull But if they had ischemic heart disease or other significant comorbidity NO
DIFFERENCE in survival
bull Active disease management and supportive care may be appropriate without starting dialysis in the ill elderly
bull Palliative care does not mean ldquono carerdquo
bull Must have end-of-life discussions
(Murtagh et al 2007)
CKD MANAGEMENTbull Diagnose cause and treat underlying conditionbull Stage per guidelinesbull Slow progression of kidney disease (ACE inhibitors)bull Monitor for complicationsmdashvolume overload hyperkalemia metabolic acidosis
hyperphosphatemia anorexia fatigue htn bone diseasebull Labs cmp cbc phos Vit D 25OH iPTH urine microscopy uric acid urine
proteincr ratio-frequency based off heat map Get sono at least oncebull Vaccinate influenza hep B pneumococcalbull Eval ASCVD risk-likely needs statinbull Possible dexa (donrsquot give bisphosphonates if GFRlt35 let specialist manage)bull Refer to nephrology when eGFR is lt30 (sometimes if higher risk-refer earlier)
CASE 1
bull 55 year old man with past medical history of headaches presents to your office for his first time visit to a PCP in over 30 years
bull He has no past history of being admitted to the hospital and he does not take any OTC medsNSAIDsherbal meds He has no history of ETOH abuse smoking or drug use
bull Vitals BP 180100 mmHg pulse 80 R 18
bull Exam No JVD S1S2 regular PMI shifted to the left no gallop no abdominal bruit pulses bilaterally equal and regular no leg edema
bull What would you order
bull EKG cbc cmp ua urine proteincr ratio lipid
LAB RESULTS
bull Labs reveal a creatinine of 22 mgdL eGFR 33 Urine shows no blood or casts Urineprotein ratio shows 1 gm protein24 hrs EKG shows LVH
bull Next step in workupbull Renal ultrasound 1st then SPEP UPEP with immunofixation serum free light chains
bull Additional labs neg Renal ultrasound shows that both kidneys are slightly reduced in size and are mildly echogenic with no mass or hydronephrosis
bull What is your diagnosis
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileMain_complications_of_persistent_high_blood_pressurepngCreative Commons License associated httpcreativecommonsorglicensesby-sa30
bull 3 months Howevermdashwe have evidence of structural abnormalities Could potentially stage at G3b A3 (red on the heat map)
bull Goal blood pressure
bull JNC 8 14090 NKF 13080
bull Additional lab needed for progression monitoring
bull Cbc renal panel phos Vit D iPTH uric acid urine micro (we already have the renal sono and urine proteincr ratio and lipid)
Selective renal angiography (left lower renal artery) after successful percutaneous balloon dilatation of the stenotic lesionFibromuscular dysplasia in an accessory renal artery causing renovascular hypertension
Secondary Hypertension
Images retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileRenal_FMD2jpg and httpcommonswikimediaorgwikiFileRenal_FMDjpgCreative Commons License associated httpcreativecommonsorglicensesby20deeden (both images)
CASE 2bull OS is a 64year old Hispanic female in for DM check She has had DM for 15+ years and is currently
taking metformin 1000mg bid Lisinopril 10mg a day atorvastatin 40mg a day Labs today showed the following
bull Hgba1c 86 cmp eGFR 50 lipid WNL proteincr ratio 650mg These results are similar to her last visit
bull Upon further hx-you find that she had a recent eye exam and has mild nonproliferaive retinopathy She does not have neuropathy or other ss
bull What further workup do you need
bull Renal sonogram urine micro iPTH vit D (25 OH) phos uric acid
bull Dx stage
bull G3a A3
bull What further treatment do you need
bull Improve glycemic control Increase Lisinopril to 20mg with a goal of 40mg Avoid NSAIDs or other nephrotoxic agents make sure meds are renally dosed monitor 3xyear nephro referral
MANAGEMENT OF CKD IN DIABETESeGFR Recommended
All patients
Yearly measurement of creatinine urinary albumin excretion potassium
45-60 Referral to a nephrologist if possibility for nondiabetickidney disease existsConsider dose adjustment of medicationsMonitor eGFR every 6 monthsMonitor electrolytes bicarbonate hemoglobin calcium phosphorus parathyroid hormone at least yearly
Assure vitamin D sufficiencyConsider bone density testingReferral for dietary counselling
American Diabetes Association Standards of Medical Care in Diabetes Microvascular complications and foot care Diabetes Care 2017 40 (Suppl 1) S88-S98
CASE 3
bull 19 year old African American woman presents to your clinic with complaints of fatigue joint pains a new rash on her face oral ulcer
bull On exam BP 15080 P 88 Afebrile 96 O2 sats on RAbull GEN No respiratory distress at restbull HEENT painless oral ulcer flat rash over malar eminences sparing the nasolabial fold pallor +bull Lungs CTAbull CVS S1S2 regularbull Abdomen soft NTbull Ext left elbow joint and bilateral wrist joints are swollen and tender
bull What would you orderbull CBC CMP ua urine microscopy (microalbumin or urine proteincr ratio) ANA esr RF anti-ccp uric acid TSH
CASE 3
bull Working dx fatigue oral ulcer joint pain
bull Basic Labs Na 135 K 55 Bicarb 18 BUN 50 Cr 35 eGFR 22 Ca 90 ANA + titer 1640
bull UA 3+ blood 3+ protein RBC casts +
bull Given these results what is the most likely diagnosis
bull What would you do
SYSTEMIC LUPUS ERYTHEMATOSUS (SLE)
bull SLE multisystemic disease Etiology unknown
bull Production of autoantibodies and immune complexes formation
bull There is renal involvement in the great majority of patients with SLE at some time of the evolution 66-90
SLE ndash LUPUS NEPHRITIS
bull Race SLE is more commonsevere in African americans than Caucasiansbull
bull Gender female-to-male ratio of 91
bull Age Most patients develop lupus nephritis early in their disease course SLE is more common among women in the third decade of life and lupus nephritis occurs in patients aged 20-40 years
bull Kidney Biopsy For staging lupus nephritis (Class 1-5)
CASE 5bull A 80 year old man who has not seen a PCP in many years
presents to your clinic for weakness for the past few months On further questioning he tells you that his bones also have been hurting lately and he has developed leg swelling in the past month or so
bull On exam bull BP 16090 P 88 Afebrilebull GEN Thin built manbull HEENT pallor presentbull Lungs clearbull CVS S1S2 regular no rub or gallopbull Abdomen soft NTbull Ext 2 + edema
CASE 5
bull Differentials
bull CHF MI Cancer arthritis
bull Labs
bull CBC CMP urine microscopy urine proteincr ratio ESR TSH EKG BNP pa and lat CXR
bull LABS Urine dipstick negative for protein or blood
bull Basic chem bull Na 136 (135-145) K 51 (35-55) Chloride 108 (96-106) Bicarb 25
Given this presentation and the labs (low anion gap and elevated calcium anemia kidney failure) what will you think of What will you order next
Serum and urine protein electrophoresis
Intratubular refractile casts with surrounding syncytial giant cell reaction with chronic tubulointerstitial nephritis and fibrosis characteristic of myeloma cast nephropathy
Kidney Biopsy
CASE STUDYbull A 35 year old African American woman was seen in the clinic for
chronic cough and dyspnea on exertion She gave history of vague symptoms of fatigue and weight loss of 20 Ibs over the last six months
bull List some differentialsbull TB sarcoid lupus thyroid problems PEbull What would you orderbull PPD cbc cmp UA TSH ANA pa and lat cxr
bull Her labs were significant for mildly elevated calcium level and a creatinine of 20 mgdL eGFR 37
bull She had 750 mg of proteinuriaday
bull PPD neg ANA neg TSH and other labs WNL
bull Assuming this is present more than 3 monthshelliphellipwhat is her ckd stage
bull G3b A3
bull What do we still need
CT scan of chest
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileAnterior_mediastinal_mass_thymomajpgCreative Commons License associated httpcreativecommonsorglicensesby20deeden
CXR ndash HILAR LYMPHADENOPATHY
WHATS NEEDED NEXT
bull Biopsy of hilar lymphadenopathy or renal biopsy
bull DX sarcoidosis
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileSarcoidosis_signs_and_symptomsjpgThis work is in the public domain in the United States because it is a work of the United States Federal Government under the terms of Title 17 Chapter 1 Section 105 of the US Code
NEWLY DX CKD
bull 1) urinalysis microscopy ultrasound proteincr ratio
bull If obstruction-treat
bull No obstruction
bull Hx critical (consider myeloma if high risk)
bull glomerular bleeding or albumin in urine
bull Yes workup for glomerular causes (ANArf hep B C upep spep ANCA complement C3 C4)
bull No sterile pyruria-consider interstitial nephritis
bull High risk renovascular disease Evaluate renovascular disease
Additional Online Resources for CKD LearningbullNational Kidney Foundation wwwkidneyorgbullUnited States Renal Data Service wwwusrdsorgbullCDCrsquos CKD Surveillance Project
httpnccdcdcgovckdbullNational Kidney Disease Education Program
(NKDEP) httpnkdepnihgov
BIBLIOGRAPHY
bull Afzali B amp Goldsmith D J (2016 June 29) Statins and chronic kidney disease (G C Curhan amp A M Sheridan Eds) Retrieved 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsstatins-and-chronic-kidney-disease
bull American Diabetes Association Standards of Medical Care in Diabetes (2017) Microvascular complications and foot care Diabetes Care 2017 (40) S88-S98
bull American Diabetes Association Standards of Medical Care in Diabetes (2017) Microvascular complications and foot care Diabetes Care 40 (suppl 1) S88-S98
bull Berns J S (2017 Mar 22) Treatment of anemia in nondialysis chronic kidney disease (T A Golper amp A M Sheridan Eds) Retrieved from UpToDate httpswww-uptodate-comproxywichitaeducontentstreatment-of-anemia-in-nondialysis-chronic-kidney-disease
bull Chan M Dall A T Fletcher K E Lu N amp Trivedi H (2007) Outcomes in patients with chronic kidney disease referred late to nephrologists a meta-analysis American Journal of Medicine 120(12) 1063-1070
bull Coresh J Selvin E amp Stevens L A (2007) Prevalence of chronic kidny disease in the United States JAMA 298(17) doi101001jama298172038
bull de Brito-Ashurst I Varagunam M Raftery M amp Yagoob M (2009) Bicarbonate supplementation slows progression of CKD and improves nutritional status Journal of American Society of Nephrology (20) 2075-2084
BIBLIOGRAPHY
bull Duncan L Heathcoat J Djurdjev O amp Levin A (2001) Screening for renal disease using serum creatinine who are we missing Nephrology Dialysis and Transplant 16(5) 1042-1046
bull Dunkler D Gao P Lee S F Heinz G Clase C M Tobe S Oberbauer R (2015 August 7) Risk prediction for early CKD in type 2 diabetes Retrieved from Clinical Journal of the American Society of Nephrology httpcjasnasnjournalsorgcontent1081371fullsid=61422554-a5f1-41ac-b696-dcd3b12bd268
bull Fatehi P amp Chi-yuan H (September 15 2016) Diagnostic approach to the patient with newly identified chronic kidney disease (G C Curhan amp A M Sheridan Eds) Retrieved May 7 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsdiagnostic-approach-to-the-patient-with-newly-identified-chronic-kidney-disease
bull Fink J e (2009) Chronic Kidney Disease as an Under-Recognized Threat to Patient Safety American journal of kidney diseases the official journal of the National Kidney Foundation 53(4) 681-688
bull Gaffo A L amp Saag K G (2008 Nov) Management of hyperuricemia and gout in CKD doihttpdxdoiorg101053jajkd200807035
bull Hebert L A amp Parikh S V (2014 June 18) Differential diagnosis and evaluation of glomerular disease (R J Glassock amp A Q Lam Eds) Retrieved May 7 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsdifferential-diagnosis-and-evaluation-of-glomerular-disease
bull Inker L Perrone R D Sterns R H amp Forman J P (2017 March 7) Assessment of kidney function Retrieved from UpToDate httpswww-uptodate-comproxywichitaeducontentsassessment-of-kidney-functionsource=search_resultampsearch=creatinineampselectedTitle=1~150
BIBLIOGRAPHY
bull James P A Ortiz E amp Et Al (2014) Evidence based guideline for the management of high blood pressure in adults (JNC) JAMA 311(5) 507-520
bull Kidney Disease Improving Global Outcomes (KDIGO) CKD Work Group (2013 January) KDIGO 2012 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease Retrieved from Kidney International Supplement httpwwwkidney-internationalorg
bull Kunz R Friedrich C Wolbers M amp Mann J F (2008) Meta-analysis effect of monotherapy and combination therapy with inhibitors of the renin angiotensin system on proteinuria in renal disease Annals of Internal Medicine 148(1) 30-48
bull Levey A Stevens L A Schmid C H Castro A F Feldman H I Kusek J W Coresh J (2009) A new equation to estimate glomerular filtration rate Annals of Internal Medicine 150(9) 604-612
bull Levin A Bakris G L Molitch M Smulders M M Williams L A amp Andress D L (2007 Jan) Prevalence of abnormal serum vitamin D PTH calcium and phosphorus in patients with chronic kidney disease results of the study to evaluate early kidney disease Kidney International 71(1) 31-38 Retrieved from PubMED
bull Mahajan A Simoni J Sheather S Broglio K Rajab M amp Wesson D (2010) Daily oral sodium bicarbonate preserves glomerular filtration rate by slowing its decline in early hypertensive nephropathy Kidney International (78_ 303-309
bull Mann J Schmieder R E amp McQueen M (2008) Renal outcomes with telmisartan ramipril or both in people at high vascular risk (the ONTARGET study) a multicentre randomised doubleblind ocntrolled trial Lancet 372(9638) 547-533
BIBLIOGRAPHY
bull Matovinović M S (2009) Pathophysiology and classification of kidney disease Retrieved from The Journal of the International Federation of Clinical Chemistry and Laboratory Medicine httpwwwifccorgifccfilesdocs20010902pdf
bull Moe S Drueke T Lameire N amp Eknoyan G (2007 Jan) Chronic kidney disease-mineral-bone disorder a new paradigmdoi101053jackd200610005
bull Murtagh F E Marsh J E Donohoe P Ekbal N J Sheerin N S amp Harris F E (2007 July) Dialysis or not A comparative survival study of patients over 75 years with chronic kidney disease stage 5 Retrieved from Nephrology Dialysis and Transplant 22(7) httpswwwncbinlmnihgovpubmed17412702
bull National Kidney Foundation (2002) KDOQI clinical practice guidelines for chronic kidney disease evaluation classification andstratification American Journal of Kidney Disease S1-S266
bull National Kidney Foundation (2014 November 5) Fact Sheets Retrieved from httpwwwkidneyorgnewsnewsroomfactsheetsFastFacts
bull Pal S (2012 June 2) Trends in chronic kidney disease Retrieved from US Pharmacist (37)6 httpswwwuspharmacistcomarticletrends-in-chronic-kidney-disease
bull Qunibi W amp Henrich W L (2017 Jan 19) Overview of chronic kidney disease-mineral and bone disorder (J Berns amp A M Sheridan Eds) Retrieved from UpToDate httpswww-uptodate-comoverview-of-chronic-kidney-disease-mineral-and-bone-disorder-ckd-mbd
bull Rosenberg M (2016 Feb 24) Overview of the management of chronic kidney disease in adults (G C Curhan amp A M Sheridan Eds) Retrieved from UpToDate UpToDate httpswww-uptodate-comproxywichitaeducontentsoverview-of-the-management-of-chronic-kidney-disease-in-adults
BIBLIOGRAPHY
bull Szczech L Stewart R C Hsu-Lin S DeLosky R J Astor B C Fox C H Vassalotti J A (2014) Primary care detection of chronic kidney disease in adults with type 2 diabetes The ADD-CKD Study (Awareness Detection and Drug Therapy in type 2 diabetes and chronic kidney disease PLOS doihttpsdoiorg101371journalpone0110535
bull USRDS (2016) Annual data report 2016 Epidemiology of kidney disease in the United States Retrieved from United States Renal Data System httpswwwusrdsorgadraspx
bull Vasudev B amp Vasudev M (2012) A model curriculum for residents rotating in nephrology MedEDPORTAL doihttpdoiorg1015766mep_2374-82658288
bull Wei L MacDonald T M Jennings C Sheng X amp Flynn R W (2013) Estimated GFR reporting is associated with decreased nonsteroidal anti-inflammatory drug prescribing and increased renal function Kidney International (84)1 174-178
chronic kidney disease in primary care
CKD as a Public Health Issue
Slide Number 3
Costs of CKD in 2013 dollarsUSRDS report
Steps to CKD Patient Care
Renal anatomy and physiology
Definition of Chronic Kidney Disease
CKD Risk Factors
Gaps in CKD Diagnosis
Slide Number 10
Steps to CKD Patient Care
creatinine
Glomerular filtration rate
Slide Number 14
Slide Number 15
Use These Equations Cautiously if at all in hellip
lab albumin creatinine ratio
The New CKD Categories
Steps to CKD Patient Care
Slide Number 20
Kidney Involvement in Systemic Diseases
Slide Number 22
Slide Number 23
DysmorphicRenal Hematuria
Slide Number 25
If you have albuminuria or hematuria-order the following labs
Prevalence of Abnormalities of Mineral Metabolism PTH in CKD
Managing CKD-MBD complications
CKD-MBD Testing
Anemia Becomes More Common as Kidney Function Declines
Detect and Manage CKD Complications
Complications-metabolic acidosis
Complications-vascular calcification
Hyperkalemia management
Hyperuricemia levels amp CKD
CKD monitoring levels 345
Slide Number 59
When to Refer to a Nephrologist
When to Refer
Steps to CKD Patient Care
Kidney transplantation
Starting Dialysis in the ElderlyhellipOr Not
Ckd management
Case 1
Slide Number 67
Lab results
Slide Number 69
Hypertensive nephropathy with proteinuria
Slide Number 71
Case 2
Slide Number 73
Management of CKD in Diabetes
Case 3
Case 3
Systemic Lupus Erythematosus (SLE)
SLE ndash Lupus Nephritis
Case 5
Case 5
Slide Number 81
Slide Number 82
Case study
Slide Number 84
CXR ndash Hilar Lymphadenopathy
Whats needed next
Slide Number 87
newly dx ckd
Slide Number 89
Bibliography
bibliography
bibliography
bibliography
bibliography
Stage 12
Stage 3
Stage 4
Stage 5
Hb le10 gdL
52
56
11
272
Hb gt10-le12 gdL
216
359
426
483
Hb le12 gdL
267
416
536
755
Stage 12
Stage 3
Stage 4
Stage 5
New CKD
Obtain ultrasound UA
microscopy albumincr ratio
Ultrasound shows
obstruction
bull Yes Relieve obstruction
bull No Is there albuminuria or glomerular bleeding (eval for glomerulo-nephritis
Fatehi amp Chi-yuan 2016
If red cells have their typical shape and color this indicates extra glomerular hematuria
Examples kidney stone disease UTI cystitis bleeding from collecting duct ureters bladder or urethra
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileReactive_lymphJPGCreative Commons License associated httpcreativecommonsorglicensesby-sa30deeden
(Vasudev amp Vasudev 2012)
DYSMORPHICRENAL HEMATURIA
bull This hematuria is characterized by bull a great variation in the size of the cells and by a high
percentage of dysmorphocytosiscasts (gt20)
bull Hematuria is usually related to glomerular bleeding bull It is typically accompanied by variable levels of albumuniuria
(Vasudev amp Vasudev 2012)
Urinary Cast Formation
Urine Microscopy can be helpful in work up of chronic kidney disease
In GNrsquos the red blood cells leak from the glomerulus into the tubules As they traverse through the tubules they can form cylindrical casts calledRBC casts
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileRedbloodcellsjpgThis image is a work of the National Institutes of Health part of the United States Department of Health and Human Services As a work of the US federal government the image is in the public domain
(Vasudev amp Vasudev 2012)
IF YOU HAVE ALBUMINURIA OR HEMATURIA-ORDER THE FOLLOWING LABS
Tests of autoimmunity Hepatitis serologies gt40 years- paraproteinassessment
ANA Hepatitis B serology (HBsAG)
Serum protein electrophoresis (SPEP)
RFanti-ccp Hepatitis C serology(HCV antibody)
Urine protein electrophoresis (UPEP)
Complement C3 C4
ANCANational Kidney Disease Education Program 2014 NIH
UPTODATE LAB RECOMENDATIONS
bull Lab to order cbc cmp urine albumincr ratio urine microscopy
bull Nephrotic pattern (protein gt35gday) ANA anti DS DNA C3 and C4 antibodies HIV HBV HCV serumurine immunofixation (amyloidosis) free light chain analysis (light chain deposition disease)
bull Nephritic pattern (red cells white cells casts variable protein) C3 C4 ANA dsDNA antineutrophil cytoplasmic antibody (ANCA) titers a streptozyme test HBV and HCV serologies HIV and in some cases blood cultures anti-glomerular basement membrane (GBM) antibodies and cryoglobulins
bull Renal biopsy(Hebert amp Parikh 2014)
EVALUATION OF NEW CKDNO OBSTRUCTION
NO EVIDENCE OF GLOMERULAR BLEEDING
High risk for multmyeloma (gt40
no nsaids no contrast
SPEP UPEP with immunofixation serum free light
chains
Evaluation depends on UA
Sterile pyuria
Eval for interstitial nephritis
Normal urinalysis
High risk for renovascular
disease
Eval for renovascular
disease
Follow serum creatinine-does it
remain stable(Fatehi amp Chi-yuan 2016)
POSSIBLE INVESTIGATIONShellip
Acute interstitial nephritisbull Drugs are the most common cause of AIN
DIABETIC NEPHROPATHY 1 CAUSE OF CKDbull Clinical syndromebull Albuminuria gt30 mg 24 hrsbull Proteinuria gt500 mg24 hrsbull Hypertension developsbull Progressive increase in proteinuriabull Progressive decline in glomerular filtration rate
bull Chronic kidney disease should be attributed to diabetic nephropathies in most patients with diabetes if albuminuria and diabetic retinopathy are both present other causes of CKD should be entertained if diabetic retinopathy is absent (KDIGO 2007)
DIABETIC NEPHROPATHY MORTALITY
bull After 40 yrs of DM
bull 10 alive if proteinuria is present
bull 70 alive if proteinuria is absent
bull Heart Disease is 15 times higher risk in those with proteinuria
bull Proteinuria = death in this population
Dunkler et al 2015
GOALS OF CARE IN CKD GLUCOSE CONTROL
bull Target HbA1c ~70 (lt695 greatest chance of reducing albuminuria)bull Can be extended above 70 with comorbidities or limited life expectancy and
risk of hypoglycemiabull Risk of hypoglycemia increases as kidney function becomes impairedbull Declining kidney function may necessitate changes to diabetes medications and
bull Just having HTN can cause proteinuriabull Usually 1-2 gms of protein a daybull Treat them like a diabetic with ACEI or ARBS and tight blood
pressure controlbull JNC-8 goal lt14090 for ptrsquos with CKDbull National kidney foundation lt14090 if ckd and no proteinuria
lt13080 if proteinuria present
(James Ortiz amp Et Al 2014)
TREATING HYPERTENSIONPROTEINURIA ACEI ORARBbull Riskbenefit should be carefully assessed in the elderly and medically fragilebull Check labs after initiation
bull If less than 30 SCr increase continue and monitorbull If more than 30 SCr increase stop ACEi and evaluate for renal artery stenosis
bull Continue until contraindication arises no absolute eGFR cutoffbull Better proteinuria suppression with low Na diet and diureticsbull Avoid volume depletionbull Avoid ACEi and ARB in combination12
bull Risk of adverse events (impaired kidney function hyperkalemia)
(Kunz Friedrich Wolbers amp Mann 2008)(Mann Schmieder amp McQueen 2008)
bull In adults gt50 yrs statin when eGFR ge 60 mlmin173m2 statin or statinezetimibe combination when eGFR lt 60 mlmin173m2
bull In adults lt 50 yrs statin if history of known CAD MI DM strokebull Aspirin is indicated for secondary but not primary prevention
Kidney Disease Improving Global Outcomes (KDIGO) CKD Work Group Kidney Int Suppls 201331-150
STATINS-RENOPROTECTIVECONTROVERSY
bull HMG-CoA reductase inhibitors (statins) in high doses can cause proteinuria
bull Possibly associated with less inflammation endothelial dysfunction and scarring in the kidney because they also block inflammatory cytokines
bull Use statins for CV disease not to treat proteinuria
(Afzali and Goldsmith 2016)
MEDICINE CAUTION
bull Hold metformin when gfr lt35 mlmin
bull GFR lt50 mlmin should alert to check all doses of meds
bull No bisphosphanates lt35 mlmin
bull No NSAIDScox 2 inhibitors lt60 mlmin
bull Atenolol ndashrenal excretion
bull BACTRIM A lot of AKI
MEDICINE CAUTION
bull Lovenox-use subcut heparinbull Apixibanbull Dabigatranbull Rivaroxibanbull Lithiumbull GABAPENTIN (ckd 4 max 300mg qd ckd 5 max 300mg qod)
STEPS TO CKD PATIENT CARE
1 CKD definition and risks2 Assess GFR albuminuria3 Determine etiology4 Assess for evidence of progression5 Assess for associated complications6 Discuss dialysistransplantation
CKD-CVD-DIABETES LINK CKD IS A DISEASE MULTIPLIER
National kidney foundation 2014
KDIGO 2017
CKD-MINERAL BONE DISORDERS
bull As kidneys fail they
bull Stop activating calcitriol (the active form of Vit D)mdashcausing calcium imbalance
bull Do not remove phosphorus from bloodmdashleading to phosphorus retention
bull The extra phosphorus pulls calcium out of bones causing them to weaken
bull High phosphorus stimulates PTH release
bull These changes (plus others) cause the start of secondary hyperparathyroidism
bull Labs
bull eGFR
bull Calcium
bull Phos
bull Vit D
bull iPTH
(Qunibi amp Henrich 2017)
PREVALENCE OF ABNORMALITIES OF MINERAL METABOLISM PTH IN CKD
bull Progression of disease ndash declining eGFR increasing proteinuria
bull Degree of proteinuria nephrotic syndrome gt 05-10 gd on ACEi or ARB therapy
bull Etiology of CKD not certain
bull Need help with disease management
bull Indications for kidney biopsy
Rosenberg 2016
WHEN TO REFER
STEPS TO CKD PATIENT CARE
1 CKD definition and risks2 Assess GFR albuminuria3 Determine etiology4 Assess for evidence of progression5 Assess for associated complications6 Discuss dialysistransplantation
KIDNEY TRANSPLANTATION
bull Treatment of choice for ESRDbull Improves quality of lifebull Waiting list time varies-3-5 yearsbull 3 year survival rate after transplantation is 83-94bull Increased risk of cancer
STARTING DIALYSIS IN THE ELDERLYhellipOR NOT
bull Among patients gt 75 yrs with stage 5 CKD who chose to NOT start dialysisbull Overall more likely to die over next 1-2 years bull But if they had ischemic heart disease or other significant comorbidity NO
DIFFERENCE in survival
bull Active disease management and supportive care may be appropriate without starting dialysis in the ill elderly
bull Palliative care does not mean ldquono carerdquo
bull Must have end-of-life discussions
(Murtagh et al 2007)
CKD MANAGEMENTbull Diagnose cause and treat underlying conditionbull Stage per guidelinesbull Slow progression of kidney disease (ACE inhibitors)bull Monitor for complicationsmdashvolume overload hyperkalemia metabolic acidosis
hyperphosphatemia anorexia fatigue htn bone diseasebull Labs cmp cbc phos Vit D 25OH iPTH urine microscopy uric acid urine
proteincr ratio-frequency based off heat map Get sono at least oncebull Vaccinate influenza hep B pneumococcalbull Eval ASCVD risk-likely needs statinbull Possible dexa (donrsquot give bisphosphonates if GFRlt35 let specialist manage)bull Refer to nephrology when eGFR is lt30 (sometimes if higher risk-refer earlier)
CASE 1
bull 55 year old man with past medical history of headaches presents to your office for his first time visit to a PCP in over 30 years
bull He has no past history of being admitted to the hospital and he does not take any OTC medsNSAIDsherbal meds He has no history of ETOH abuse smoking or drug use
bull Vitals BP 180100 mmHg pulse 80 R 18
bull Exam No JVD S1S2 regular PMI shifted to the left no gallop no abdominal bruit pulses bilaterally equal and regular no leg edema
bull What would you order
bull EKG cbc cmp ua urine proteincr ratio lipid
LAB RESULTS
bull Labs reveal a creatinine of 22 mgdL eGFR 33 Urine shows no blood or casts Urineprotein ratio shows 1 gm protein24 hrs EKG shows LVH
bull Next step in workupbull Renal ultrasound 1st then SPEP UPEP with immunofixation serum free light chains
bull Additional labs neg Renal ultrasound shows that both kidneys are slightly reduced in size and are mildly echogenic with no mass or hydronephrosis
bull What is your diagnosis
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileMain_complications_of_persistent_high_blood_pressurepngCreative Commons License associated httpcreativecommonsorglicensesby-sa30
bull 3 months Howevermdashwe have evidence of structural abnormalities Could potentially stage at G3b A3 (red on the heat map)
bull Goal blood pressure
bull JNC 8 14090 NKF 13080
bull Additional lab needed for progression monitoring
bull Cbc renal panel phos Vit D iPTH uric acid urine micro (we already have the renal sono and urine proteincr ratio and lipid)
Selective renal angiography (left lower renal artery) after successful percutaneous balloon dilatation of the stenotic lesionFibromuscular dysplasia in an accessory renal artery causing renovascular hypertension
Secondary Hypertension
Images retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileRenal_FMD2jpg and httpcommonswikimediaorgwikiFileRenal_FMDjpgCreative Commons License associated httpcreativecommonsorglicensesby20deeden (both images)
CASE 2bull OS is a 64year old Hispanic female in for DM check She has had DM for 15+ years and is currently
taking metformin 1000mg bid Lisinopril 10mg a day atorvastatin 40mg a day Labs today showed the following
bull Hgba1c 86 cmp eGFR 50 lipid WNL proteincr ratio 650mg These results are similar to her last visit
bull Upon further hx-you find that she had a recent eye exam and has mild nonproliferaive retinopathy She does not have neuropathy or other ss
bull What further workup do you need
bull Renal sonogram urine micro iPTH vit D (25 OH) phos uric acid
bull Dx stage
bull G3a A3
bull What further treatment do you need
bull Improve glycemic control Increase Lisinopril to 20mg with a goal of 40mg Avoid NSAIDs or other nephrotoxic agents make sure meds are renally dosed monitor 3xyear nephro referral
MANAGEMENT OF CKD IN DIABETESeGFR Recommended
All patients
Yearly measurement of creatinine urinary albumin excretion potassium
45-60 Referral to a nephrologist if possibility for nondiabetickidney disease existsConsider dose adjustment of medicationsMonitor eGFR every 6 monthsMonitor electrolytes bicarbonate hemoglobin calcium phosphorus parathyroid hormone at least yearly
Assure vitamin D sufficiencyConsider bone density testingReferral for dietary counselling
American Diabetes Association Standards of Medical Care in Diabetes Microvascular complications and foot care Diabetes Care 2017 40 (Suppl 1) S88-S98
CASE 3
bull 19 year old African American woman presents to your clinic with complaints of fatigue joint pains a new rash on her face oral ulcer
bull On exam BP 15080 P 88 Afebrile 96 O2 sats on RAbull GEN No respiratory distress at restbull HEENT painless oral ulcer flat rash over malar eminences sparing the nasolabial fold pallor +bull Lungs CTAbull CVS S1S2 regularbull Abdomen soft NTbull Ext left elbow joint and bilateral wrist joints are swollen and tender
bull What would you orderbull CBC CMP ua urine microscopy (microalbumin or urine proteincr ratio) ANA esr RF anti-ccp uric acid TSH
CASE 3
bull Working dx fatigue oral ulcer joint pain
bull Basic Labs Na 135 K 55 Bicarb 18 BUN 50 Cr 35 eGFR 22 Ca 90 ANA + titer 1640
bull UA 3+ blood 3+ protein RBC casts +
bull Given these results what is the most likely diagnosis
bull What would you do
SYSTEMIC LUPUS ERYTHEMATOSUS (SLE)
bull SLE multisystemic disease Etiology unknown
bull Production of autoantibodies and immune complexes formation
bull There is renal involvement in the great majority of patients with SLE at some time of the evolution 66-90
SLE ndash LUPUS NEPHRITIS
bull Race SLE is more commonsevere in African americans than Caucasiansbull
bull Gender female-to-male ratio of 91
bull Age Most patients develop lupus nephritis early in their disease course SLE is more common among women in the third decade of life and lupus nephritis occurs in patients aged 20-40 years
bull Kidney Biopsy For staging lupus nephritis (Class 1-5)
CASE 5bull A 80 year old man who has not seen a PCP in many years
presents to your clinic for weakness for the past few months On further questioning he tells you that his bones also have been hurting lately and he has developed leg swelling in the past month or so
bull On exam bull BP 16090 P 88 Afebrilebull GEN Thin built manbull HEENT pallor presentbull Lungs clearbull CVS S1S2 regular no rub or gallopbull Abdomen soft NTbull Ext 2 + edema
CASE 5
bull Differentials
bull CHF MI Cancer arthritis
bull Labs
bull CBC CMP urine microscopy urine proteincr ratio ESR TSH EKG BNP pa and lat CXR
bull LABS Urine dipstick negative for protein or blood
bull Basic chem bull Na 136 (135-145) K 51 (35-55) Chloride 108 (96-106) Bicarb 25
Given this presentation and the labs (low anion gap and elevated calcium anemia kidney failure) what will you think of What will you order next
Serum and urine protein electrophoresis
Intratubular refractile casts with surrounding syncytial giant cell reaction with chronic tubulointerstitial nephritis and fibrosis characteristic of myeloma cast nephropathy
Kidney Biopsy
CASE STUDYbull A 35 year old African American woman was seen in the clinic for
chronic cough and dyspnea on exertion She gave history of vague symptoms of fatigue and weight loss of 20 Ibs over the last six months
bull List some differentialsbull TB sarcoid lupus thyroid problems PEbull What would you orderbull PPD cbc cmp UA TSH ANA pa and lat cxr
bull Her labs were significant for mildly elevated calcium level and a creatinine of 20 mgdL eGFR 37
bull She had 750 mg of proteinuriaday
bull PPD neg ANA neg TSH and other labs WNL
bull Assuming this is present more than 3 monthshelliphellipwhat is her ckd stage
bull G3b A3
bull What do we still need
CT scan of chest
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileAnterior_mediastinal_mass_thymomajpgCreative Commons License associated httpcreativecommonsorglicensesby20deeden
CXR ndash HILAR LYMPHADENOPATHY
WHATS NEEDED NEXT
bull Biopsy of hilar lymphadenopathy or renal biopsy
bull DX sarcoidosis
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileSarcoidosis_signs_and_symptomsjpgThis work is in the public domain in the United States because it is a work of the United States Federal Government under the terms of Title 17 Chapter 1 Section 105 of the US Code
NEWLY DX CKD
bull 1) urinalysis microscopy ultrasound proteincr ratio
bull If obstruction-treat
bull No obstruction
bull Hx critical (consider myeloma if high risk)
bull glomerular bleeding or albumin in urine
bull Yes workup for glomerular causes (ANArf hep B C upep spep ANCA complement C3 C4)
bull No sterile pyruria-consider interstitial nephritis
bull High risk renovascular disease Evaluate renovascular disease
Additional Online Resources for CKD LearningbullNational Kidney Foundation wwwkidneyorgbullUnited States Renal Data Service wwwusrdsorgbullCDCrsquos CKD Surveillance Project
httpnccdcdcgovckdbullNational Kidney Disease Education Program
(NKDEP) httpnkdepnihgov
BIBLIOGRAPHY
bull Afzali B amp Goldsmith D J (2016 June 29) Statins and chronic kidney disease (G C Curhan amp A M Sheridan Eds) Retrieved 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsstatins-and-chronic-kidney-disease
bull American Diabetes Association Standards of Medical Care in Diabetes (2017) Microvascular complications and foot care Diabetes Care 2017 (40) S88-S98
bull American Diabetes Association Standards of Medical Care in Diabetes (2017) Microvascular complications and foot care Diabetes Care 40 (suppl 1) S88-S98
bull Berns J S (2017 Mar 22) Treatment of anemia in nondialysis chronic kidney disease (T A Golper amp A M Sheridan Eds) Retrieved from UpToDate httpswww-uptodate-comproxywichitaeducontentstreatment-of-anemia-in-nondialysis-chronic-kidney-disease
bull Chan M Dall A T Fletcher K E Lu N amp Trivedi H (2007) Outcomes in patients with chronic kidney disease referred late to nephrologists a meta-analysis American Journal of Medicine 120(12) 1063-1070
bull Coresh J Selvin E amp Stevens L A (2007) Prevalence of chronic kidny disease in the United States JAMA 298(17) doi101001jama298172038
bull de Brito-Ashurst I Varagunam M Raftery M amp Yagoob M (2009) Bicarbonate supplementation slows progression of CKD and improves nutritional status Journal of American Society of Nephrology (20) 2075-2084
BIBLIOGRAPHY
bull Duncan L Heathcoat J Djurdjev O amp Levin A (2001) Screening for renal disease using serum creatinine who are we missing Nephrology Dialysis and Transplant 16(5) 1042-1046
bull Dunkler D Gao P Lee S F Heinz G Clase C M Tobe S Oberbauer R (2015 August 7) Risk prediction for early CKD in type 2 diabetes Retrieved from Clinical Journal of the American Society of Nephrology httpcjasnasnjournalsorgcontent1081371fullsid=61422554-a5f1-41ac-b696-dcd3b12bd268
bull Fatehi P amp Chi-yuan H (September 15 2016) Diagnostic approach to the patient with newly identified chronic kidney disease (G C Curhan amp A M Sheridan Eds) Retrieved May 7 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsdiagnostic-approach-to-the-patient-with-newly-identified-chronic-kidney-disease
bull Fink J e (2009) Chronic Kidney Disease as an Under-Recognized Threat to Patient Safety American journal of kidney diseases the official journal of the National Kidney Foundation 53(4) 681-688
bull Gaffo A L amp Saag K G (2008 Nov) Management of hyperuricemia and gout in CKD doihttpdxdoiorg101053jajkd200807035
bull Hebert L A amp Parikh S V (2014 June 18) Differential diagnosis and evaluation of glomerular disease (R J Glassock amp A Q Lam Eds) Retrieved May 7 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsdifferential-diagnosis-and-evaluation-of-glomerular-disease
bull Inker L Perrone R D Sterns R H amp Forman J P (2017 March 7) Assessment of kidney function Retrieved from UpToDate httpswww-uptodate-comproxywichitaeducontentsassessment-of-kidney-functionsource=search_resultampsearch=creatinineampselectedTitle=1~150
BIBLIOGRAPHY
bull James P A Ortiz E amp Et Al (2014) Evidence based guideline for the management of high blood pressure in adults (JNC) JAMA 311(5) 507-520
bull Kidney Disease Improving Global Outcomes (KDIGO) CKD Work Group (2013 January) KDIGO 2012 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease Retrieved from Kidney International Supplement httpwwwkidney-internationalorg
bull Kunz R Friedrich C Wolbers M amp Mann J F (2008) Meta-analysis effect of monotherapy and combination therapy with inhibitors of the renin angiotensin system on proteinuria in renal disease Annals of Internal Medicine 148(1) 30-48
bull Levey A Stevens L A Schmid C H Castro A F Feldman H I Kusek J W Coresh J (2009) A new equation to estimate glomerular filtration rate Annals of Internal Medicine 150(9) 604-612
bull Levin A Bakris G L Molitch M Smulders M M Williams L A amp Andress D L (2007 Jan) Prevalence of abnormal serum vitamin D PTH calcium and phosphorus in patients with chronic kidney disease results of the study to evaluate early kidney disease Kidney International 71(1) 31-38 Retrieved from PubMED
bull Mahajan A Simoni J Sheather S Broglio K Rajab M amp Wesson D (2010) Daily oral sodium bicarbonate preserves glomerular filtration rate by slowing its decline in early hypertensive nephropathy Kidney International (78_ 303-309
bull Mann J Schmieder R E amp McQueen M (2008) Renal outcomes with telmisartan ramipril or both in people at high vascular risk (the ONTARGET study) a multicentre randomised doubleblind ocntrolled trial Lancet 372(9638) 547-533
BIBLIOGRAPHY
bull Matovinović M S (2009) Pathophysiology and classification of kidney disease Retrieved from The Journal of the International Federation of Clinical Chemistry and Laboratory Medicine httpwwwifccorgifccfilesdocs20010902pdf
bull Moe S Drueke T Lameire N amp Eknoyan G (2007 Jan) Chronic kidney disease-mineral-bone disorder a new paradigmdoi101053jackd200610005
bull Murtagh F E Marsh J E Donohoe P Ekbal N J Sheerin N S amp Harris F E (2007 July) Dialysis or not A comparative survival study of patients over 75 years with chronic kidney disease stage 5 Retrieved from Nephrology Dialysis and Transplant 22(7) httpswwwncbinlmnihgovpubmed17412702
bull National Kidney Foundation (2002) KDOQI clinical practice guidelines for chronic kidney disease evaluation classification andstratification American Journal of Kidney Disease S1-S266
bull National Kidney Foundation (2014 November 5) Fact Sheets Retrieved from httpwwwkidneyorgnewsnewsroomfactsheetsFastFacts
bull Pal S (2012 June 2) Trends in chronic kidney disease Retrieved from US Pharmacist (37)6 httpswwwuspharmacistcomarticletrends-in-chronic-kidney-disease
bull Qunibi W amp Henrich W L (2017 Jan 19) Overview of chronic kidney disease-mineral and bone disorder (J Berns amp A M Sheridan Eds) Retrieved from UpToDate httpswww-uptodate-comoverview-of-chronic-kidney-disease-mineral-and-bone-disorder-ckd-mbd
bull Rosenberg M (2016 Feb 24) Overview of the management of chronic kidney disease in adults (G C Curhan amp A M Sheridan Eds) Retrieved from UpToDate UpToDate httpswww-uptodate-comproxywichitaeducontentsoverview-of-the-management-of-chronic-kidney-disease-in-adults
BIBLIOGRAPHY
bull Szczech L Stewart R C Hsu-Lin S DeLosky R J Astor B C Fox C H Vassalotti J A (2014) Primary care detection of chronic kidney disease in adults with type 2 diabetes The ADD-CKD Study (Awareness Detection and Drug Therapy in type 2 diabetes and chronic kidney disease PLOS doihttpsdoiorg101371journalpone0110535
bull USRDS (2016) Annual data report 2016 Epidemiology of kidney disease in the United States Retrieved from United States Renal Data System httpswwwusrdsorgadraspx
bull Vasudev B amp Vasudev M (2012) A model curriculum for residents rotating in nephrology MedEDPORTAL doihttpdoiorg1015766mep_2374-82658288
bull Wei L MacDonald T M Jennings C Sheng X amp Flynn R W (2013) Estimated GFR reporting is associated with decreased nonsteroidal anti-inflammatory drug prescribing and increased renal function Kidney International (84)1 174-178
chronic kidney disease in primary care
CKD as a Public Health Issue
Slide Number 3
Costs of CKD in 2013 dollarsUSRDS report
Steps to CKD Patient Care
Renal anatomy and physiology
Definition of Chronic Kidney Disease
CKD Risk Factors
Gaps in CKD Diagnosis
Slide Number 10
Steps to CKD Patient Care
creatinine
Glomerular filtration rate
Slide Number 14
Slide Number 15
Use These Equations Cautiously if at all in hellip
lab albumin creatinine ratio
The New CKD Categories
Steps to CKD Patient Care
Slide Number 20
Kidney Involvement in Systemic Diseases
Slide Number 22
Slide Number 23
DysmorphicRenal Hematuria
Slide Number 25
If you have albuminuria or hematuria-order the following labs
Prevalence of Abnormalities of Mineral Metabolism PTH in CKD
Managing CKD-MBD complications
CKD-MBD Testing
Anemia Becomes More Common as Kidney Function Declines
Detect and Manage CKD Complications
Complications-metabolic acidosis
Complications-vascular calcification
Hyperkalemia management
Hyperuricemia levels amp CKD
CKD monitoring levels 345
Slide Number 59
When to Refer to a Nephrologist
When to Refer
Steps to CKD Patient Care
Kidney transplantation
Starting Dialysis in the ElderlyhellipOr Not
Ckd management
Case 1
Slide Number 67
Lab results
Slide Number 69
Hypertensive nephropathy with proteinuria
Slide Number 71
Case 2
Slide Number 73
Management of CKD in Diabetes
Case 3
Case 3
Systemic Lupus Erythematosus (SLE)
SLE ndash Lupus Nephritis
Case 5
Case 5
Slide Number 81
Slide Number 82
Case study
Slide Number 84
CXR ndash Hilar Lymphadenopathy
Whats needed next
Slide Number 87
newly dx ckd
Slide Number 89
Bibliography
bibliography
bibliography
bibliography
bibliography
Stage 12
Stage 3
Stage 4
Stage 5
Hb le10 gdL
52
56
11
272
Hb gt10-le12 gdL
216
359
426
483
Hb le12 gdL
267
416
536
755
Stage 12
Stage 3
Stage 4
Stage 5
If red cells have their typical shape and color this indicates extra glomerular hematuria
Examples kidney stone disease UTI cystitis bleeding from collecting duct ureters bladder or urethra
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileReactive_lymphJPGCreative Commons License associated httpcreativecommonsorglicensesby-sa30deeden
(Vasudev amp Vasudev 2012)
DYSMORPHICRENAL HEMATURIA
bull This hematuria is characterized by bull a great variation in the size of the cells and by a high
percentage of dysmorphocytosiscasts (gt20)
bull Hematuria is usually related to glomerular bleeding bull It is typically accompanied by variable levels of albumuniuria
(Vasudev amp Vasudev 2012)
Urinary Cast Formation
Urine Microscopy can be helpful in work up of chronic kidney disease
In GNrsquos the red blood cells leak from the glomerulus into the tubules As they traverse through the tubules they can form cylindrical casts calledRBC casts
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileRedbloodcellsjpgThis image is a work of the National Institutes of Health part of the United States Department of Health and Human Services As a work of the US federal government the image is in the public domain
(Vasudev amp Vasudev 2012)
IF YOU HAVE ALBUMINURIA OR HEMATURIA-ORDER THE FOLLOWING LABS
Tests of autoimmunity Hepatitis serologies gt40 years- paraproteinassessment
ANA Hepatitis B serology (HBsAG)
Serum protein electrophoresis (SPEP)
RFanti-ccp Hepatitis C serology(HCV antibody)
Urine protein electrophoresis (UPEP)
Complement C3 C4
ANCANational Kidney Disease Education Program 2014 NIH
UPTODATE LAB RECOMENDATIONS
bull Lab to order cbc cmp urine albumincr ratio urine microscopy
bull Nephrotic pattern (protein gt35gday) ANA anti DS DNA C3 and C4 antibodies HIV HBV HCV serumurine immunofixation (amyloidosis) free light chain analysis (light chain deposition disease)
bull Nephritic pattern (red cells white cells casts variable protein) C3 C4 ANA dsDNA antineutrophil cytoplasmic antibody (ANCA) titers a streptozyme test HBV and HCV serologies HIV and in some cases blood cultures anti-glomerular basement membrane (GBM) antibodies and cryoglobulins
bull Renal biopsy(Hebert amp Parikh 2014)
EVALUATION OF NEW CKDNO OBSTRUCTION
NO EVIDENCE OF GLOMERULAR BLEEDING
High risk for multmyeloma (gt40
no nsaids no contrast
SPEP UPEP with immunofixation serum free light
chains
Evaluation depends on UA
Sterile pyuria
Eval for interstitial nephritis
Normal urinalysis
High risk for renovascular
disease
Eval for renovascular
disease
Follow serum creatinine-does it
remain stable(Fatehi amp Chi-yuan 2016)
POSSIBLE INVESTIGATIONShellip
Acute interstitial nephritisbull Drugs are the most common cause of AIN
DIABETIC NEPHROPATHY 1 CAUSE OF CKDbull Clinical syndromebull Albuminuria gt30 mg 24 hrsbull Proteinuria gt500 mg24 hrsbull Hypertension developsbull Progressive increase in proteinuriabull Progressive decline in glomerular filtration rate
bull Chronic kidney disease should be attributed to diabetic nephropathies in most patients with diabetes if albuminuria and diabetic retinopathy are both present other causes of CKD should be entertained if diabetic retinopathy is absent (KDIGO 2007)
DIABETIC NEPHROPATHY MORTALITY
bull After 40 yrs of DM
bull 10 alive if proteinuria is present
bull 70 alive if proteinuria is absent
bull Heart Disease is 15 times higher risk in those with proteinuria
bull Proteinuria = death in this population
Dunkler et al 2015
GOALS OF CARE IN CKD GLUCOSE CONTROL
bull Target HbA1c ~70 (lt695 greatest chance of reducing albuminuria)bull Can be extended above 70 with comorbidities or limited life expectancy and
risk of hypoglycemiabull Risk of hypoglycemia increases as kidney function becomes impairedbull Declining kidney function may necessitate changes to diabetes medications and
bull Just having HTN can cause proteinuriabull Usually 1-2 gms of protein a daybull Treat them like a diabetic with ACEI or ARBS and tight blood
pressure controlbull JNC-8 goal lt14090 for ptrsquos with CKDbull National kidney foundation lt14090 if ckd and no proteinuria
lt13080 if proteinuria present
(James Ortiz amp Et Al 2014)
TREATING HYPERTENSIONPROTEINURIA ACEI ORARBbull Riskbenefit should be carefully assessed in the elderly and medically fragilebull Check labs after initiation
bull If less than 30 SCr increase continue and monitorbull If more than 30 SCr increase stop ACEi and evaluate for renal artery stenosis
bull Continue until contraindication arises no absolute eGFR cutoffbull Better proteinuria suppression with low Na diet and diureticsbull Avoid volume depletionbull Avoid ACEi and ARB in combination12
bull Risk of adverse events (impaired kidney function hyperkalemia)
(Kunz Friedrich Wolbers amp Mann 2008)(Mann Schmieder amp McQueen 2008)
bull In adults gt50 yrs statin when eGFR ge 60 mlmin173m2 statin or statinezetimibe combination when eGFR lt 60 mlmin173m2
bull In adults lt 50 yrs statin if history of known CAD MI DM strokebull Aspirin is indicated for secondary but not primary prevention
Kidney Disease Improving Global Outcomes (KDIGO) CKD Work Group Kidney Int Suppls 201331-150
STATINS-RENOPROTECTIVECONTROVERSY
bull HMG-CoA reductase inhibitors (statins) in high doses can cause proteinuria
bull Possibly associated with less inflammation endothelial dysfunction and scarring in the kidney because they also block inflammatory cytokines
bull Use statins for CV disease not to treat proteinuria
(Afzali and Goldsmith 2016)
MEDICINE CAUTION
bull Hold metformin when gfr lt35 mlmin
bull GFR lt50 mlmin should alert to check all doses of meds
bull No bisphosphanates lt35 mlmin
bull No NSAIDScox 2 inhibitors lt60 mlmin
bull Atenolol ndashrenal excretion
bull BACTRIM A lot of AKI
MEDICINE CAUTION
bull Lovenox-use subcut heparinbull Apixibanbull Dabigatranbull Rivaroxibanbull Lithiumbull GABAPENTIN (ckd 4 max 300mg qd ckd 5 max 300mg qod)
STEPS TO CKD PATIENT CARE
1 CKD definition and risks2 Assess GFR albuminuria3 Determine etiology4 Assess for evidence of progression5 Assess for associated complications6 Discuss dialysistransplantation
CKD-CVD-DIABETES LINK CKD IS A DISEASE MULTIPLIER
National kidney foundation 2014
KDIGO 2017
CKD-MINERAL BONE DISORDERS
bull As kidneys fail they
bull Stop activating calcitriol (the active form of Vit D)mdashcausing calcium imbalance
bull Do not remove phosphorus from bloodmdashleading to phosphorus retention
bull The extra phosphorus pulls calcium out of bones causing them to weaken
bull High phosphorus stimulates PTH release
bull These changes (plus others) cause the start of secondary hyperparathyroidism
bull Labs
bull eGFR
bull Calcium
bull Phos
bull Vit D
bull iPTH
(Qunibi amp Henrich 2017)
PREVALENCE OF ABNORMALITIES OF MINERAL METABOLISM PTH IN CKD
bull Progression of disease ndash declining eGFR increasing proteinuria
bull Degree of proteinuria nephrotic syndrome gt 05-10 gd on ACEi or ARB therapy
bull Etiology of CKD not certain
bull Need help with disease management
bull Indications for kidney biopsy
Rosenberg 2016
WHEN TO REFER
STEPS TO CKD PATIENT CARE
1 CKD definition and risks2 Assess GFR albuminuria3 Determine etiology4 Assess for evidence of progression5 Assess for associated complications6 Discuss dialysistransplantation
KIDNEY TRANSPLANTATION
bull Treatment of choice for ESRDbull Improves quality of lifebull Waiting list time varies-3-5 yearsbull 3 year survival rate after transplantation is 83-94bull Increased risk of cancer
STARTING DIALYSIS IN THE ELDERLYhellipOR NOT
bull Among patients gt 75 yrs with stage 5 CKD who chose to NOT start dialysisbull Overall more likely to die over next 1-2 years bull But if they had ischemic heart disease or other significant comorbidity NO
DIFFERENCE in survival
bull Active disease management and supportive care may be appropriate without starting dialysis in the ill elderly
bull Palliative care does not mean ldquono carerdquo
bull Must have end-of-life discussions
(Murtagh et al 2007)
CKD MANAGEMENTbull Diagnose cause and treat underlying conditionbull Stage per guidelinesbull Slow progression of kidney disease (ACE inhibitors)bull Monitor for complicationsmdashvolume overload hyperkalemia metabolic acidosis
hyperphosphatemia anorexia fatigue htn bone diseasebull Labs cmp cbc phos Vit D 25OH iPTH urine microscopy uric acid urine
proteincr ratio-frequency based off heat map Get sono at least oncebull Vaccinate influenza hep B pneumococcalbull Eval ASCVD risk-likely needs statinbull Possible dexa (donrsquot give bisphosphonates if GFRlt35 let specialist manage)bull Refer to nephrology when eGFR is lt30 (sometimes if higher risk-refer earlier)
CASE 1
bull 55 year old man with past medical history of headaches presents to your office for his first time visit to a PCP in over 30 years
bull He has no past history of being admitted to the hospital and he does not take any OTC medsNSAIDsherbal meds He has no history of ETOH abuse smoking or drug use
bull Vitals BP 180100 mmHg pulse 80 R 18
bull Exam No JVD S1S2 regular PMI shifted to the left no gallop no abdominal bruit pulses bilaterally equal and regular no leg edema
bull What would you order
bull EKG cbc cmp ua urine proteincr ratio lipid
LAB RESULTS
bull Labs reveal a creatinine of 22 mgdL eGFR 33 Urine shows no blood or casts Urineprotein ratio shows 1 gm protein24 hrs EKG shows LVH
bull Next step in workupbull Renal ultrasound 1st then SPEP UPEP with immunofixation serum free light chains
bull Additional labs neg Renal ultrasound shows that both kidneys are slightly reduced in size and are mildly echogenic with no mass or hydronephrosis
bull What is your diagnosis
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileMain_complications_of_persistent_high_blood_pressurepngCreative Commons License associated httpcreativecommonsorglicensesby-sa30
bull 3 months Howevermdashwe have evidence of structural abnormalities Could potentially stage at G3b A3 (red on the heat map)
bull Goal blood pressure
bull JNC 8 14090 NKF 13080
bull Additional lab needed for progression monitoring
bull Cbc renal panel phos Vit D iPTH uric acid urine micro (we already have the renal sono and urine proteincr ratio and lipid)
Selective renal angiography (left lower renal artery) after successful percutaneous balloon dilatation of the stenotic lesionFibromuscular dysplasia in an accessory renal artery causing renovascular hypertension
Secondary Hypertension
Images retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileRenal_FMD2jpg and httpcommonswikimediaorgwikiFileRenal_FMDjpgCreative Commons License associated httpcreativecommonsorglicensesby20deeden (both images)
CASE 2bull OS is a 64year old Hispanic female in for DM check She has had DM for 15+ years and is currently
taking metformin 1000mg bid Lisinopril 10mg a day atorvastatin 40mg a day Labs today showed the following
bull Hgba1c 86 cmp eGFR 50 lipid WNL proteincr ratio 650mg These results are similar to her last visit
bull Upon further hx-you find that she had a recent eye exam and has mild nonproliferaive retinopathy She does not have neuropathy or other ss
bull What further workup do you need
bull Renal sonogram urine micro iPTH vit D (25 OH) phos uric acid
bull Dx stage
bull G3a A3
bull What further treatment do you need
bull Improve glycemic control Increase Lisinopril to 20mg with a goal of 40mg Avoid NSAIDs or other nephrotoxic agents make sure meds are renally dosed monitor 3xyear nephro referral
MANAGEMENT OF CKD IN DIABETESeGFR Recommended
All patients
Yearly measurement of creatinine urinary albumin excretion potassium
45-60 Referral to a nephrologist if possibility for nondiabetickidney disease existsConsider dose adjustment of medicationsMonitor eGFR every 6 monthsMonitor electrolytes bicarbonate hemoglobin calcium phosphorus parathyroid hormone at least yearly
Assure vitamin D sufficiencyConsider bone density testingReferral for dietary counselling
American Diabetes Association Standards of Medical Care in Diabetes Microvascular complications and foot care Diabetes Care 2017 40 (Suppl 1) S88-S98
CASE 3
bull 19 year old African American woman presents to your clinic with complaints of fatigue joint pains a new rash on her face oral ulcer
bull On exam BP 15080 P 88 Afebrile 96 O2 sats on RAbull GEN No respiratory distress at restbull HEENT painless oral ulcer flat rash over malar eminences sparing the nasolabial fold pallor +bull Lungs CTAbull CVS S1S2 regularbull Abdomen soft NTbull Ext left elbow joint and bilateral wrist joints are swollen and tender
bull What would you orderbull CBC CMP ua urine microscopy (microalbumin or urine proteincr ratio) ANA esr RF anti-ccp uric acid TSH
CASE 3
bull Working dx fatigue oral ulcer joint pain
bull Basic Labs Na 135 K 55 Bicarb 18 BUN 50 Cr 35 eGFR 22 Ca 90 ANA + titer 1640
bull UA 3+ blood 3+ protein RBC casts +
bull Given these results what is the most likely diagnosis
bull What would you do
SYSTEMIC LUPUS ERYTHEMATOSUS (SLE)
bull SLE multisystemic disease Etiology unknown
bull Production of autoantibodies and immune complexes formation
bull There is renal involvement in the great majority of patients with SLE at some time of the evolution 66-90
SLE ndash LUPUS NEPHRITIS
bull Race SLE is more commonsevere in African americans than Caucasiansbull
bull Gender female-to-male ratio of 91
bull Age Most patients develop lupus nephritis early in their disease course SLE is more common among women in the third decade of life and lupus nephritis occurs in patients aged 20-40 years
bull Kidney Biopsy For staging lupus nephritis (Class 1-5)
CASE 5bull A 80 year old man who has not seen a PCP in many years
presents to your clinic for weakness for the past few months On further questioning he tells you that his bones also have been hurting lately and he has developed leg swelling in the past month or so
bull On exam bull BP 16090 P 88 Afebrilebull GEN Thin built manbull HEENT pallor presentbull Lungs clearbull CVS S1S2 regular no rub or gallopbull Abdomen soft NTbull Ext 2 + edema
CASE 5
bull Differentials
bull CHF MI Cancer arthritis
bull Labs
bull CBC CMP urine microscopy urine proteincr ratio ESR TSH EKG BNP pa and lat CXR
bull LABS Urine dipstick negative for protein or blood
bull Basic chem bull Na 136 (135-145) K 51 (35-55) Chloride 108 (96-106) Bicarb 25
Given this presentation and the labs (low anion gap and elevated calcium anemia kidney failure) what will you think of What will you order next
Serum and urine protein electrophoresis
Intratubular refractile casts with surrounding syncytial giant cell reaction with chronic tubulointerstitial nephritis and fibrosis characteristic of myeloma cast nephropathy
Kidney Biopsy
CASE STUDYbull A 35 year old African American woman was seen in the clinic for
chronic cough and dyspnea on exertion She gave history of vague symptoms of fatigue and weight loss of 20 Ibs over the last six months
bull List some differentialsbull TB sarcoid lupus thyroid problems PEbull What would you orderbull PPD cbc cmp UA TSH ANA pa and lat cxr
bull Her labs were significant for mildly elevated calcium level and a creatinine of 20 mgdL eGFR 37
bull She had 750 mg of proteinuriaday
bull PPD neg ANA neg TSH and other labs WNL
bull Assuming this is present more than 3 monthshelliphellipwhat is her ckd stage
bull G3b A3
bull What do we still need
CT scan of chest
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileAnterior_mediastinal_mass_thymomajpgCreative Commons License associated httpcreativecommonsorglicensesby20deeden
CXR ndash HILAR LYMPHADENOPATHY
WHATS NEEDED NEXT
bull Biopsy of hilar lymphadenopathy or renal biopsy
bull DX sarcoidosis
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileSarcoidosis_signs_and_symptomsjpgThis work is in the public domain in the United States because it is a work of the United States Federal Government under the terms of Title 17 Chapter 1 Section 105 of the US Code
NEWLY DX CKD
bull 1) urinalysis microscopy ultrasound proteincr ratio
bull If obstruction-treat
bull No obstruction
bull Hx critical (consider myeloma if high risk)
bull glomerular bleeding or albumin in urine
bull Yes workup for glomerular causes (ANArf hep B C upep spep ANCA complement C3 C4)
bull No sterile pyruria-consider interstitial nephritis
bull High risk renovascular disease Evaluate renovascular disease
Additional Online Resources for CKD LearningbullNational Kidney Foundation wwwkidneyorgbullUnited States Renal Data Service wwwusrdsorgbullCDCrsquos CKD Surveillance Project
httpnccdcdcgovckdbullNational Kidney Disease Education Program
(NKDEP) httpnkdepnihgov
BIBLIOGRAPHY
bull Afzali B amp Goldsmith D J (2016 June 29) Statins and chronic kidney disease (G C Curhan amp A M Sheridan Eds) Retrieved 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsstatins-and-chronic-kidney-disease
bull American Diabetes Association Standards of Medical Care in Diabetes (2017) Microvascular complications and foot care Diabetes Care 2017 (40) S88-S98
bull American Diabetes Association Standards of Medical Care in Diabetes (2017) Microvascular complications and foot care Diabetes Care 40 (suppl 1) S88-S98
bull Berns J S (2017 Mar 22) Treatment of anemia in nondialysis chronic kidney disease (T A Golper amp A M Sheridan Eds) Retrieved from UpToDate httpswww-uptodate-comproxywichitaeducontentstreatment-of-anemia-in-nondialysis-chronic-kidney-disease
bull Chan M Dall A T Fletcher K E Lu N amp Trivedi H (2007) Outcomes in patients with chronic kidney disease referred late to nephrologists a meta-analysis American Journal of Medicine 120(12) 1063-1070
bull Coresh J Selvin E amp Stevens L A (2007) Prevalence of chronic kidny disease in the United States JAMA 298(17) doi101001jama298172038
bull de Brito-Ashurst I Varagunam M Raftery M amp Yagoob M (2009) Bicarbonate supplementation slows progression of CKD and improves nutritional status Journal of American Society of Nephrology (20) 2075-2084
BIBLIOGRAPHY
bull Duncan L Heathcoat J Djurdjev O amp Levin A (2001) Screening for renal disease using serum creatinine who are we missing Nephrology Dialysis and Transplant 16(5) 1042-1046
bull Dunkler D Gao P Lee S F Heinz G Clase C M Tobe S Oberbauer R (2015 August 7) Risk prediction for early CKD in type 2 diabetes Retrieved from Clinical Journal of the American Society of Nephrology httpcjasnasnjournalsorgcontent1081371fullsid=61422554-a5f1-41ac-b696-dcd3b12bd268
bull Fatehi P amp Chi-yuan H (September 15 2016) Diagnostic approach to the patient with newly identified chronic kidney disease (G C Curhan amp A M Sheridan Eds) Retrieved May 7 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsdiagnostic-approach-to-the-patient-with-newly-identified-chronic-kidney-disease
bull Fink J e (2009) Chronic Kidney Disease as an Under-Recognized Threat to Patient Safety American journal of kidney diseases the official journal of the National Kidney Foundation 53(4) 681-688
bull Gaffo A L amp Saag K G (2008 Nov) Management of hyperuricemia and gout in CKD doihttpdxdoiorg101053jajkd200807035
bull Hebert L A amp Parikh S V (2014 June 18) Differential diagnosis and evaluation of glomerular disease (R J Glassock amp A Q Lam Eds) Retrieved May 7 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsdifferential-diagnosis-and-evaluation-of-glomerular-disease
bull Inker L Perrone R D Sterns R H amp Forman J P (2017 March 7) Assessment of kidney function Retrieved from UpToDate httpswww-uptodate-comproxywichitaeducontentsassessment-of-kidney-functionsource=search_resultampsearch=creatinineampselectedTitle=1~150
BIBLIOGRAPHY
bull James P A Ortiz E amp Et Al (2014) Evidence based guideline for the management of high blood pressure in adults (JNC) JAMA 311(5) 507-520
bull Kidney Disease Improving Global Outcomes (KDIGO) CKD Work Group (2013 January) KDIGO 2012 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease Retrieved from Kidney International Supplement httpwwwkidney-internationalorg
bull Kunz R Friedrich C Wolbers M amp Mann J F (2008) Meta-analysis effect of monotherapy and combination therapy with inhibitors of the renin angiotensin system on proteinuria in renal disease Annals of Internal Medicine 148(1) 30-48
bull Levey A Stevens L A Schmid C H Castro A F Feldman H I Kusek J W Coresh J (2009) A new equation to estimate glomerular filtration rate Annals of Internal Medicine 150(9) 604-612
bull Levin A Bakris G L Molitch M Smulders M M Williams L A amp Andress D L (2007 Jan) Prevalence of abnormal serum vitamin D PTH calcium and phosphorus in patients with chronic kidney disease results of the study to evaluate early kidney disease Kidney International 71(1) 31-38 Retrieved from PubMED
bull Mahajan A Simoni J Sheather S Broglio K Rajab M amp Wesson D (2010) Daily oral sodium bicarbonate preserves glomerular filtration rate by slowing its decline in early hypertensive nephropathy Kidney International (78_ 303-309
bull Mann J Schmieder R E amp McQueen M (2008) Renal outcomes with telmisartan ramipril or both in people at high vascular risk (the ONTARGET study) a multicentre randomised doubleblind ocntrolled trial Lancet 372(9638) 547-533
BIBLIOGRAPHY
bull Matovinović M S (2009) Pathophysiology and classification of kidney disease Retrieved from The Journal of the International Federation of Clinical Chemistry and Laboratory Medicine httpwwwifccorgifccfilesdocs20010902pdf
bull Moe S Drueke T Lameire N amp Eknoyan G (2007 Jan) Chronic kidney disease-mineral-bone disorder a new paradigmdoi101053jackd200610005
bull Murtagh F E Marsh J E Donohoe P Ekbal N J Sheerin N S amp Harris F E (2007 July) Dialysis or not A comparative survival study of patients over 75 years with chronic kidney disease stage 5 Retrieved from Nephrology Dialysis and Transplant 22(7) httpswwwncbinlmnihgovpubmed17412702
bull National Kidney Foundation (2002) KDOQI clinical practice guidelines for chronic kidney disease evaluation classification andstratification American Journal of Kidney Disease S1-S266
bull National Kidney Foundation (2014 November 5) Fact Sheets Retrieved from httpwwwkidneyorgnewsnewsroomfactsheetsFastFacts
bull Pal S (2012 June 2) Trends in chronic kidney disease Retrieved from US Pharmacist (37)6 httpswwwuspharmacistcomarticletrends-in-chronic-kidney-disease
bull Qunibi W amp Henrich W L (2017 Jan 19) Overview of chronic kidney disease-mineral and bone disorder (J Berns amp A M Sheridan Eds) Retrieved from UpToDate httpswww-uptodate-comoverview-of-chronic-kidney-disease-mineral-and-bone-disorder-ckd-mbd
bull Rosenberg M (2016 Feb 24) Overview of the management of chronic kidney disease in adults (G C Curhan amp A M Sheridan Eds) Retrieved from UpToDate UpToDate httpswww-uptodate-comproxywichitaeducontentsoverview-of-the-management-of-chronic-kidney-disease-in-adults
BIBLIOGRAPHY
bull Szczech L Stewart R C Hsu-Lin S DeLosky R J Astor B C Fox C H Vassalotti J A (2014) Primary care detection of chronic kidney disease in adults with type 2 diabetes The ADD-CKD Study (Awareness Detection and Drug Therapy in type 2 diabetes and chronic kidney disease PLOS doihttpsdoiorg101371journalpone0110535
bull USRDS (2016) Annual data report 2016 Epidemiology of kidney disease in the United States Retrieved from United States Renal Data System httpswwwusrdsorgadraspx
bull Vasudev B amp Vasudev M (2012) A model curriculum for residents rotating in nephrology MedEDPORTAL doihttpdoiorg1015766mep_2374-82658288
bull Wei L MacDonald T M Jennings C Sheng X amp Flynn R W (2013) Estimated GFR reporting is associated with decreased nonsteroidal anti-inflammatory drug prescribing and increased renal function Kidney International (84)1 174-178
chronic kidney disease in primary care
CKD as a Public Health Issue
Slide Number 3
Costs of CKD in 2013 dollarsUSRDS report
Steps to CKD Patient Care
Renal anatomy and physiology
Definition of Chronic Kidney Disease
CKD Risk Factors
Gaps in CKD Diagnosis
Slide Number 10
Steps to CKD Patient Care
creatinine
Glomerular filtration rate
Slide Number 14
Slide Number 15
Use These Equations Cautiously if at all in hellip
lab albumin creatinine ratio
The New CKD Categories
Steps to CKD Patient Care
Slide Number 20
Kidney Involvement in Systemic Diseases
Slide Number 22
Slide Number 23
DysmorphicRenal Hematuria
Slide Number 25
If you have albuminuria or hematuria-order the following labs
Prevalence of Abnormalities of Mineral Metabolism PTH in CKD
Managing CKD-MBD complications
CKD-MBD Testing
Anemia Becomes More Common as Kidney Function Declines
Detect and Manage CKD Complications
Complications-metabolic acidosis
Complications-vascular calcification
Hyperkalemia management
Hyperuricemia levels amp CKD
CKD monitoring levels 345
Slide Number 59
When to Refer to a Nephrologist
When to Refer
Steps to CKD Patient Care
Kidney transplantation
Starting Dialysis in the ElderlyhellipOr Not
Ckd management
Case 1
Slide Number 67
Lab results
Slide Number 69
Hypertensive nephropathy with proteinuria
Slide Number 71
Case 2
Slide Number 73
Management of CKD in Diabetes
Case 3
Case 3
Systemic Lupus Erythematosus (SLE)
SLE ndash Lupus Nephritis
Case 5
Case 5
Slide Number 81
Slide Number 82
Case study
Slide Number 84
CXR ndash Hilar Lymphadenopathy
Whats needed next
Slide Number 87
newly dx ckd
Slide Number 89
Bibliography
bibliography
bibliography
bibliography
bibliography
Stage 12
Stage 3
Stage 4
Stage 5
Hb le10 gdL
52
56
11
272
Hb gt10-le12 gdL
216
359
426
483
Hb le12 gdL
267
416
536
755
Stage 12
Stage 3
Stage 4
Stage 5
DYSMORPHICRENAL HEMATURIA
bull This hematuria is characterized by bull a great variation in the size of the cells and by a high
percentage of dysmorphocytosiscasts (gt20)
bull Hematuria is usually related to glomerular bleeding bull It is typically accompanied by variable levels of albumuniuria
(Vasudev amp Vasudev 2012)
Urinary Cast Formation
Urine Microscopy can be helpful in work up of chronic kidney disease
In GNrsquos the red blood cells leak from the glomerulus into the tubules As they traverse through the tubules they can form cylindrical casts calledRBC casts
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileRedbloodcellsjpgThis image is a work of the National Institutes of Health part of the United States Department of Health and Human Services As a work of the US federal government the image is in the public domain
(Vasudev amp Vasudev 2012)
IF YOU HAVE ALBUMINURIA OR HEMATURIA-ORDER THE FOLLOWING LABS
Tests of autoimmunity Hepatitis serologies gt40 years- paraproteinassessment
ANA Hepatitis B serology (HBsAG)
Serum protein electrophoresis (SPEP)
RFanti-ccp Hepatitis C serology(HCV antibody)
Urine protein electrophoresis (UPEP)
Complement C3 C4
ANCANational Kidney Disease Education Program 2014 NIH
UPTODATE LAB RECOMENDATIONS
bull Lab to order cbc cmp urine albumincr ratio urine microscopy
bull Nephrotic pattern (protein gt35gday) ANA anti DS DNA C3 and C4 antibodies HIV HBV HCV serumurine immunofixation (amyloidosis) free light chain analysis (light chain deposition disease)
bull Nephritic pattern (red cells white cells casts variable protein) C3 C4 ANA dsDNA antineutrophil cytoplasmic antibody (ANCA) titers a streptozyme test HBV and HCV serologies HIV and in some cases blood cultures anti-glomerular basement membrane (GBM) antibodies and cryoglobulins
bull Renal biopsy(Hebert amp Parikh 2014)
EVALUATION OF NEW CKDNO OBSTRUCTION
NO EVIDENCE OF GLOMERULAR BLEEDING
High risk for multmyeloma (gt40
no nsaids no contrast
SPEP UPEP with immunofixation serum free light
chains
Evaluation depends on UA
Sterile pyuria
Eval for interstitial nephritis
Normal urinalysis
High risk for renovascular
disease
Eval for renovascular
disease
Follow serum creatinine-does it
remain stable(Fatehi amp Chi-yuan 2016)
POSSIBLE INVESTIGATIONShellip
Acute interstitial nephritisbull Drugs are the most common cause of AIN
DIABETIC NEPHROPATHY 1 CAUSE OF CKDbull Clinical syndromebull Albuminuria gt30 mg 24 hrsbull Proteinuria gt500 mg24 hrsbull Hypertension developsbull Progressive increase in proteinuriabull Progressive decline in glomerular filtration rate
bull Chronic kidney disease should be attributed to diabetic nephropathies in most patients with diabetes if albuminuria and diabetic retinopathy are both present other causes of CKD should be entertained if diabetic retinopathy is absent (KDIGO 2007)
DIABETIC NEPHROPATHY MORTALITY
bull After 40 yrs of DM
bull 10 alive if proteinuria is present
bull 70 alive if proteinuria is absent
bull Heart Disease is 15 times higher risk in those with proteinuria
bull Proteinuria = death in this population
Dunkler et al 2015
GOALS OF CARE IN CKD GLUCOSE CONTROL
bull Target HbA1c ~70 (lt695 greatest chance of reducing albuminuria)bull Can be extended above 70 with comorbidities or limited life expectancy and
risk of hypoglycemiabull Risk of hypoglycemia increases as kidney function becomes impairedbull Declining kidney function may necessitate changes to diabetes medications and
bull Just having HTN can cause proteinuriabull Usually 1-2 gms of protein a daybull Treat them like a diabetic with ACEI or ARBS and tight blood
pressure controlbull JNC-8 goal lt14090 for ptrsquos with CKDbull National kidney foundation lt14090 if ckd and no proteinuria
lt13080 if proteinuria present
(James Ortiz amp Et Al 2014)
TREATING HYPERTENSIONPROTEINURIA ACEI ORARBbull Riskbenefit should be carefully assessed in the elderly and medically fragilebull Check labs after initiation
bull If less than 30 SCr increase continue and monitorbull If more than 30 SCr increase stop ACEi and evaluate for renal artery stenosis
bull Continue until contraindication arises no absolute eGFR cutoffbull Better proteinuria suppression with low Na diet and diureticsbull Avoid volume depletionbull Avoid ACEi and ARB in combination12
bull Risk of adverse events (impaired kidney function hyperkalemia)
(Kunz Friedrich Wolbers amp Mann 2008)(Mann Schmieder amp McQueen 2008)
bull In adults gt50 yrs statin when eGFR ge 60 mlmin173m2 statin or statinezetimibe combination when eGFR lt 60 mlmin173m2
bull In adults lt 50 yrs statin if history of known CAD MI DM strokebull Aspirin is indicated for secondary but not primary prevention
Kidney Disease Improving Global Outcomes (KDIGO) CKD Work Group Kidney Int Suppls 201331-150
STATINS-RENOPROTECTIVECONTROVERSY
bull HMG-CoA reductase inhibitors (statins) in high doses can cause proteinuria
bull Possibly associated with less inflammation endothelial dysfunction and scarring in the kidney because they also block inflammatory cytokines
bull Use statins for CV disease not to treat proteinuria
(Afzali and Goldsmith 2016)
MEDICINE CAUTION
bull Hold metformin when gfr lt35 mlmin
bull GFR lt50 mlmin should alert to check all doses of meds
bull No bisphosphanates lt35 mlmin
bull No NSAIDScox 2 inhibitors lt60 mlmin
bull Atenolol ndashrenal excretion
bull BACTRIM A lot of AKI
MEDICINE CAUTION
bull Lovenox-use subcut heparinbull Apixibanbull Dabigatranbull Rivaroxibanbull Lithiumbull GABAPENTIN (ckd 4 max 300mg qd ckd 5 max 300mg qod)
STEPS TO CKD PATIENT CARE
1 CKD definition and risks2 Assess GFR albuminuria3 Determine etiology4 Assess for evidence of progression5 Assess for associated complications6 Discuss dialysistransplantation
CKD-CVD-DIABETES LINK CKD IS A DISEASE MULTIPLIER
National kidney foundation 2014
KDIGO 2017
CKD-MINERAL BONE DISORDERS
bull As kidneys fail they
bull Stop activating calcitriol (the active form of Vit D)mdashcausing calcium imbalance
bull Do not remove phosphorus from bloodmdashleading to phosphorus retention
bull The extra phosphorus pulls calcium out of bones causing them to weaken
bull High phosphorus stimulates PTH release
bull These changes (plus others) cause the start of secondary hyperparathyroidism
bull Labs
bull eGFR
bull Calcium
bull Phos
bull Vit D
bull iPTH
(Qunibi amp Henrich 2017)
PREVALENCE OF ABNORMALITIES OF MINERAL METABOLISM PTH IN CKD
bull Progression of disease ndash declining eGFR increasing proteinuria
bull Degree of proteinuria nephrotic syndrome gt 05-10 gd on ACEi or ARB therapy
bull Etiology of CKD not certain
bull Need help with disease management
bull Indications for kidney biopsy
Rosenberg 2016
WHEN TO REFER
STEPS TO CKD PATIENT CARE
1 CKD definition and risks2 Assess GFR albuminuria3 Determine etiology4 Assess for evidence of progression5 Assess for associated complications6 Discuss dialysistransplantation
KIDNEY TRANSPLANTATION
bull Treatment of choice for ESRDbull Improves quality of lifebull Waiting list time varies-3-5 yearsbull 3 year survival rate after transplantation is 83-94bull Increased risk of cancer
STARTING DIALYSIS IN THE ELDERLYhellipOR NOT
bull Among patients gt 75 yrs with stage 5 CKD who chose to NOT start dialysisbull Overall more likely to die over next 1-2 years bull But if they had ischemic heart disease or other significant comorbidity NO
DIFFERENCE in survival
bull Active disease management and supportive care may be appropriate without starting dialysis in the ill elderly
bull Palliative care does not mean ldquono carerdquo
bull Must have end-of-life discussions
(Murtagh et al 2007)
CKD MANAGEMENTbull Diagnose cause and treat underlying conditionbull Stage per guidelinesbull Slow progression of kidney disease (ACE inhibitors)bull Monitor for complicationsmdashvolume overload hyperkalemia metabolic acidosis
hyperphosphatemia anorexia fatigue htn bone diseasebull Labs cmp cbc phos Vit D 25OH iPTH urine microscopy uric acid urine
proteincr ratio-frequency based off heat map Get sono at least oncebull Vaccinate influenza hep B pneumococcalbull Eval ASCVD risk-likely needs statinbull Possible dexa (donrsquot give bisphosphonates if GFRlt35 let specialist manage)bull Refer to nephrology when eGFR is lt30 (sometimes if higher risk-refer earlier)
CASE 1
bull 55 year old man with past medical history of headaches presents to your office for his first time visit to a PCP in over 30 years
bull He has no past history of being admitted to the hospital and he does not take any OTC medsNSAIDsherbal meds He has no history of ETOH abuse smoking or drug use
bull Vitals BP 180100 mmHg pulse 80 R 18
bull Exam No JVD S1S2 regular PMI shifted to the left no gallop no abdominal bruit pulses bilaterally equal and regular no leg edema
bull What would you order
bull EKG cbc cmp ua urine proteincr ratio lipid
LAB RESULTS
bull Labs reveal a creatinine of 22 mgdL eGFR 33 Urine shows no blood or casts Urineprotein ratio shows 1 gm protein24 hrs EKG shows LVH
bull Next step in workupbull Renal ultrasound 1st then SPEP UPEP with immunofixation serum free light chains
bull Additional labs neg Renal ultrasound shows that both kidneys are slightly reduced in size and are mildly echogenic with no mass or hydronephrosis
bull What is your diagnosis
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileMain_complications_of_persistent_high_blood_pressurepngCreative Commons License associated httpcreativecommonsorglicensesby-sa30
bull 3 months Howevermdashwe have evidence of structural abnormalities Could potentially stage at G3b A3 (red on the heat map)
bull Goal blood pressure
bull JNC 8 14090 NKF 13080
bull Additional lab needed for progression monitoring
bull Cbc renal panel phos Vit D iPTH uric acid urine micro (we already have the renal sono and urine proteincr ratio and lipid)
Selective renal angiography (left lower renal artery) after successful percutaneous balloon dilatation of the stenotic lesionFibromuscular dysplasia in an accessory renal artery causing renovascular hypertension
Secondary Hypertension
Images retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileRenal_FMD2jpg and httpcommonswikimediaorgwikiFileRenal_FMDjpgCreative Commons License associated httpcreativecommonsorglicensesby20deeden (both images)
CASE 2bull OS is a 64year old Hispanic female in for DM check She has had DM for 15+ years and is currently
taking metformin 1000mg bid Lisinopril 10mg a day atorvastatin 40mg a day Labs today showed the following
bull Hgba1c 86 cmp eGFR 50 lipid WNL proteincr ratio 650mg These results are similar to her last visit
bull Upon further hx-you find that she had a recent eye exam and has mild nonproliferaive retinopathy She does not have neuropathy or other ss
bull What further workup do you need
bull Renal sonogram urine micro iPTH vit D (25 OH) phos uric acid
bull Dx stage
bull G3a A3
bull What further treatment do you need
bull Improve glycemic control Increase Lisinopril to 20mg with a goal of 40mg Avoid NSAIDs or other nephrotoxic agents make sure meds are renally dosed monitor 3xyear nephro referral
MANAGEMENT OF CKD IN DIABETESeGFR Recommended
All patients
Yearly measurement of creatinine urinary albumin excretion potassium
45-60 Referral to a nephrologist if possibility for nondiabetickidney disease existsConsider dose adjustment of medicationsMonitor eGFR every 6 monthsMonitor electrolytes bicarbonate hemoglobin calcium phosphorus parathyroid hormone at least yearly
Assure vitamin D sufficiencyConsider bone density testingReferral for dietary counselling
American Diabetes Association Standards of Medical Care in Diabetes Microvascular complications and foot care Diabetes Care 2017 40 (Suppl 1) S88-S98
CASE 3
bull 19 year old African American woman presents to your clinic with complaints of fatigue joint pains a new rash on her face oral ulcer
bull On exam BP 15080 P 88 Afebrile 96 O2 sats on RAbull GEN No respiratory distress at restbull HEENT painless oral ulcer flat rash over malar eminences sparing the nasolabial fold pallor +bull Lungs CTAbull CVS S1S2 regularbull Abdomen soft NTbull Ext left elbow joint and bilateral wrist joints are swollen and tender
bull What would you orderbull CBC CMP ua urine microscopy (microalbumin or urine proteincr ratio) ANA esr RF anti-ccp uric acid TSH
CASE 3
bull Working dx fatigue oral ulcer joint pain
bull Basic Labs Na 135 K 55 Bicarb 18 BUN 50 Cr 35 eGFR 22 Ca 90 ANA + titer 1640
bull UA 3+ blood 3+ protein RBC casts +
bull Given these results what is the most likely diagnosis
bull What would you do
SYSTEMIC LUPUS ERYTHEMATOSUS (SLE)
bull SLE multisystemic disease Etiology unknown
bull Production of autoantibodies and immune complexes formation
bull There is renal involvement in the great majority of patients with SLE at some time of the evolution 66-90
SLE ndash LUPUS NEPHRITIS
bull Race SLE is more commonsevere in African americans than Caucasiansbull
bull Gender female-to-male ratio of 91
bull Age Most patients develop lupus nephritis early in their disease course SLE is more common among women in the third decade of life and lupus nephritis occurs in patients aged 20-40 years
bull Kidney Biopsy For staging lupus nephritis (Class 1-5)
CASE 5bull A 80 year old man who has not seen a PCP in many years
presents to your clinic for weakness for the past few months On further questioning he tells you that his bones also have been hurting lately and he has developed leg swelling in the past month or so
bull On exam bull BP 16090 P 88 Afebrilebull GEN Thin built manbull HEENT pallor presentbull Lungs clearbull CVS S1S2 regular no rub or gallopbull Abdomen soft NTbull Ext 2 + edema
CASE 5
bull Differentials
bull CHF MI Cancer arthritis
bull Labs
bull CBC CMP urine microscopy urine proteincr ratio ESR TSH EKG BNP pa and lat CXR
bull LABS Urine dipstick negative for protein or blood
bull Basic chem bull Na 136 (135-145) K 51 (35-55) Chloride 108 (96-106) Bicarb 25
Given this presentation and the labs (low anion gap and elevated calcium anemia kidney failure) what will you think of What will you order next
Serum and urine protein electrophoresis
Intratubular refractile casts with surrounding syncytial giant cell reaction with chronic tubulointerstitial nephritis and fibrosis characteristic of myeloma cast nephropathy
Kidney Biopsy
CASE STUDYbull A 35 year old African American woman was seen in the clinic for
chronic cough and dyspnea on exertion She gave history of vague symptoms of fatigue and weight loss of 20 Ibs over the last six months
bull List some differentialsbull TB sarcoid lupus thyroid problems PEbull What would you orderbull PPD cbc cmp UA TSH ANA pa and lat cxr
bull Her labs were significant for mildly elevated calcium level and a creatinine of 20 mgdL eGFR 37
bull She had 750 mg of proteinuriaday
bull PPD neg ANA neg TSH and other labs WNL
bull Assuming this is present more than 3 monthshelliphellipwhat is her ckd stage
bull G3b A3
bull What do we still need
CT scan of chest
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileAnterior_mediastinal_mass_thymomajpgCreative Commons License associated httpcreativecommonsorglicensesby20deeden
CXR ndash HILAR LYMPHADENOPATHY
WHATS NEEDED NEXT
bull Biopsy of hilar lymphadenopathy or renal biopsy
bull DX sarcoidosis
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileSarcoidosis_signs_and_symptomsjpgThis work is in the public domain in the United States because it is a work of the United States Federal Government under the terms of Title 17 Chapter 1 Section 105 of the US Code
NEWLY DX CKD
bull 1) urinalysis microscopy ultrasound proteincr ratio
bull If obstruction-treat
bull No obstruction
bull Hx critical (consider myeloma if high risk)
bull glomerular bleeding or albumin in urine
bull Yes workup for glomerular causes (ANArf hep B C upep spep ANCA complement C3 C4)
bull No sterile pyruria-consider interstitial nephritis
bull High risk renovascular disease Evaluate renovascular disease
Additional Online Resources for CKD LearningbullNational Kidney Foundation wwwkidneyorgbullUnited States Renal Data Service wwwusrdsorgbullCDCrsquos CKD Surveillance Project
httpnccdcdcgovckdbullNational Kidney Disease Education Program
(NKDEP) httpnkdepnihgov
BIBLIOGRAPHY
bull Afzali B amp Goldsmith D J (2016 June 29) Statins and chronic kidney disease (G C Curhan amp A M Sheridan Eds) Retrieved 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsstatins-and-chronic-kidney-disease
bull American Diabetes Association Standards of Medical Care in Diabetes (2017) Microvascular complications and foot care Diabetes Care 2017 (40) S88-S98
bull American Diabetes Association Standards of Medical Care in Diabetes (2017) Microvascular complications and foot care Diabetes Care 40 (suppl 1) S88-S98
bull Berns J S (2017 Mar 22) Treatment of anemia in nondialysis chronic kidney disease (T A Golper amp A M Sheridan Eds) Retrieved from UpToDate httpswww-uptodate-comproxywichitaeducontentstreatment-of-anemia-in-nondialysis-chronic-kidney-disease
bull Chan M Dall A T Fletcher K E Lu N amp Trivedi H (2007) Outcomes in patients with chronic kidney disease referred late to nephrologists a meta-analysis American Journal of Medicine 120(12) 1063-1070
bull Coresh J Selvin E amp Stevens L A (2007) Prevalence of chronic kidny disease in the United States JAMA 298(17) doi101001jama298172038
bull de Brito-Ashurst I Varagunam M Raftery M amp Yagoob M (2009) Bicarbonate supplementation slows progression of CKD and improves nutritional status Journal of American Society of Nephrology (20) 2075-2084
BIBLIOGRAPHY
bull Duncan L Heathcoat J Djurdjev O amp Levin A (2001) Screening for renal disease using serum creatinine who are we missing Nephrology Dialysis and Transplant 16(5) 1042-1046
bull Dunkler D Gao P Lee S F Heinz G Clase C M Tobe S Oberbauer R (2015 August 7) Risk prediction for early CKD in type 2 diabetes Retrieved from Clinical Journal of the American Society of Nephrology httpcjasnasnjournalsorgcontent1081371fullsid=61422554-a5f1-41ac-b696-dcd3b12bd268
bull Fatehi P amp Chi-yuan H (September 15 2016) Diagnostic approach to the patient with newly identified chronic kidney disease (G C Curhan amp A M Sheridan Eds) Retrieved May 7 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsdiagnostic-approach-to-the-patient-with-newly-identified-chronic-kidney-disease
bull Fink J e (2009) Chronic Kidney Disease as an Under-Recognized Threat to Patient Safety American journal of kidney diseases the official journal of the National Kidney Foundation 53(4) 681-688
bull Gaffo A L amp Saag K G (2008 Nov) Management of hyperuricemia and gout in CKD doihttpdxdoiorg101053jajkd200807035
bull Hebert L A amp Parikh S V (2014 June 18) Differential diagnosis and evaluation of glomerular disease (R J Glassock amp A Q Lam Eds) Retrieved May 7 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsdifferential-diagnosis-and-evaluation-of-glomerular-disease
bull Inker L Perrone R D Sterns R H amp Forman J P (2017 March 7) Assessment of kidney function Retrieved from UpToDate httpswww-uptodate-comproxywichitaeducontentsassessment-of-kidney-functionsource=search_resultampsearch=creatinineampselectedTitle=1~150
BIBLIOGRAPHY
bull James P A Ortiz E amp Et Al (2014) Evidence based guideline for the management of high blood pressure in adults (JNC) JAMA 311(5) 507-520
bull Kidney Disease Improving Global Outcomes (KDIGO) CKD Work Group (2013 January) KDIGO 2012 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease Retrieved from Kidney International Supplement httpwwwkidney-internationalorg
bull Kunz R Friedrich C Wolbers M amp Mann J F (2008) Meta-analysis effect of monotherapy and combination therapy with inhibitors of the renin angiotensin system on proteinuria in renal disease Annals of Internal Medicine 148(1) 30-48
bull Levey A Stevens L A Schmid C H Castro A F Feldman H I Kusek J W Coresh J (2009) A new equation to estimate glomerular filtration rate Annals of Internal Medicine 150(9) 604-612
bull Levin A Bakris G L Molitch M Smulders M M Williams L A amp Andress D L (2007 Jan) Prevalence of abnormal serum vitamin D PTH calcium and phosphorus in patients with chronic kidney disease results of the study to evaluate early kidney disease Kidney International 71(1) 31-38 Retrieved from PubMED
bull Mahajan A Simoni J Sheather S Broglio K Rajab M amp Wesson D (2010) Daily oral sodium bicarbonate preserves glomerular filtration rate by slowing its decline in early hypertensive nephropathy Kidney International (78_ 303-309
bull Mann J Schmieder R E amp McQueen M (2008) Renal outcomes with telmisartan ramipril or both in people at high vascular risk (the ONTARGET study) a multicentre randomised doubleblind ocntrolled trial Lancet 372(9638) 547-533
BIBLIOGRAPHY
bull Matovinović M S (2009) Pathophysiology and classification of kidney disease Retrieved from The Journal of the International Federation of Clinical Chemistry and Laboratory Medicine httpwwwifccorgifccfilesdocs20010902pdf
bull Moe S Drueke T Lameire N amp Eknoyan G (2007 Jan) Chronic kidney disease-mineral-bone disorder a new paradigmdoi101053jackd200610005
bull Murtagh F E Marsh J E Donohoe P Ekbal N J Sheerin N S amp Harris F E (2007 July) Dialysis or not A comparative survival study of patients over 75 years with chronic kidney disease stage 5 Retrieved from Nephrology Dialysis and Transplant 22(7) httpswwwncbinlmnihgovpubmed17412702
bull National Kidney Foundation (2002) KDOQI clinical practice guidelines for chronic kidney disease evaluation classification andstratification American Journal of Kidney Disease S1-S266
bull National Kidney Foundation (2014 November 5) Fact Sheets Retrieved from httpwwwkidneyorgnewsnewsroomfactsheetsFastFacts
bull Pal S (2012 June 2) Trends in chronic kidney disease Retrieved from US Pharmacist (37)6 httpswwwuspharmacistcomarticletrends-in-chronic-kidney-disease
bull Qunibi W amp Henrich W L (2017 Jan 19) Overview of chronic kidney disease-mineral and bone disorder (J Berns amp A M Sheridan Eds) Retrieved from UpToDate httpswww-uptodate-comoverview-of-chronic-kidney-disease-mineral-and-bone-disorder-ckd-mbd
bull Rosenberg M (2016 Feb 24) Overview of the management of chronic kidney disease in adults (G C Curhan amp A M Sheridan Eds) Retrieved from UpToDate UpToDate httpswww-uptodate-comproxywichitaeducontentsoverview-of-the-management-of-chronic-kidney-disease-in-adults
BIBLIOGRAPHY
bull Szczech L Stewart R C Hsu-Lin S DeLosky R J Astor B C Fox C H Vassalotti J A (2014) Primary care detection of chronic kidney disease in adults with type 2 diabetes The ADD-CKD Study (Awareness Detection and Drug Therapy in type 2 diabetes and chronic kidney disease PLOS doihttpsdoiorg101371journalpone0110535
bull USRDS (2016) Annual data report 2016 Epidemiology of kidney disease in the United States Retrieved from United States Renal Data System httpswwwusrdsorgadraspx
bull Vasudev B amp Vasudev M (2012) A model curriculum for residents rotating in nephrology MedEDPORTAL doihttpdoiorg1015766mep_2374-82658288
bull Wei L MacDonald T M Jennings C Sheng X amp Flynn R W (2013) Estimated GFR reporting is associated with decreased nonsteroidal anti-inflammatory drug prescribing and increased renal function Kidney International (84)1 174-178
chronic kidney disease in primary care
CKD as a Public Health Issue
Slide Number 3
Costs of CKD in 2013 dollarsUSRDS report
Steps to CKD Patient Care
Renal anatomy and physiology
Definition of Chronic Kidney Disease
CKD Risk Factors
Gaps in CKD Diagnosis
Slide Number 10
Steps to CKD Patient Care
creatinine
Glomerular filtration rate
Slide Number 14
Slide Number 15
Use These Equations Cautiously if at all in hellip
lab albumin creatinine ratio
The New CKD Categories
Steps to CKD Patient Care
Slide Number 20
Kidney Involvement in Systemic Diseases
Slide Number 22
Slide Number 23
DysmorphicRenal Hematuria
Slide Number 25
If you have albuminuria or hematuria-order the following labs
Prevalence of Abnormalities of Mineral Metabolism PTH in CKD
Managing CKD-MBD complications
CKD-MBD Testing
Anemia Becomes More Common as Kidney Function Declines
Detect and Manage CKD Complications
Complications-metabolic acidosis
Complications-vascular calcification
Hyperkalemia management
Hyperuricemia levels amp CKD
CKD monitoring levels 345
Slide Number 59
When to Refer to a Nephrologist
When to Refer
Steps to CKD Patient Care
Kidney transplantation
Starting Dialysis in the ElderlyhellipOr Not
Ckd management
Case 1
Slide Number 67
Lab results
Slide Number 69
Hypertensive nephropathy with proteinuria
Slide Number 71
Case 2
Slide Number 73
Management of CKD in Diabetes
Case 3
Case 3
Systemic Lupus Erythematosus (SLE)
SLE ndash Lupus Nephritis
Case 5
Case 5
Slide Number 81
Slide Number 82
Case study
Slide Number 84
CXR ndash Hilar Lymphadenopathy
Whats needed next
Slide Number 87
newly dx ckd
Slide Number 89
Bibliography
bibliography
bibliography
bibliography
bibliography
Stage 12
Stage 3
Stage 4
Stage 5
Hb le10 gdL
52
56
11
272
Hb gt10-le12 gdL
216
359
426
483
Hb le12 gdL
267
416
536
755
Stage 12
Stage 3
Stage 4
Stage 5
Urinary Cast Formation
Urine Microscopy can be helpful in work up of chronic kidney disease
In GNrsquos the red blood cells leak from the glomerulus into the tubules As they traverse through the tubules they can form cylindrical casts calledRBC casts
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileRedbloodcellsjpgThis image is a work of the National Institutes of Health part of the United States Department of Health and Human Services As a work of the US federal government the image is in the public domain
(Vasudev amp Vasudev 2012)
IF YOU HAVE ALBUMINURIA OR HEMATURIA-ORDER THE FOLLOWING LABS
Tests of autoimmunity Hepatitis serologies gt40 years- paraproteinassessment
ANA Hepatitis B serology (HBsAG)
Serum protein electrophoresis (SPEP)
RFanti-ccp Hepatitis C serology(HCV antibody)
Urine protein electrophoresis (UPEP)
Complement C3 C4
ANCANational Kidney Disease Education Program 2014 NIH
UPTODATE LAB RECOMENDATIONS
bull Lab to order cbc cmp urine albumincr ratio urine microscopy
bull Nephrotic pattern (protein gt35gday) ANA anti DS DNA C3 and C4 antibodies HIV HBV HCV serumurine immunofixation (amyloidosis) free light chain analysis (light chain deposition disease)
bull Nephritic pattern (red cells white cells casts variable protein) C3 C4 ANA dsDNA antineutrophil cytoplasmic antibody (ANCA) titers a streptozyme test HBV and HCV serologies HIV and in some cases blood cultures anti-glomerular basement membrane (GBM) antibodies and cryoglobulins
bull Renal biopsy(Hebert amp Parikh 2014)
EVALUATION OF NEW CKDNO OBSTRUCTION
NO EVIDENCE OF GLOMERULAR BLEEDING
High risk for multmyeloma (gt40
no nsaids no contrast
SPEP UPEP with immunofixation serum free light
chains
Evaluation depends on UA
Sterile pyuria
Eval for interstitial nephritis
Normal urinalysis
High risk for renovascular
disease
Eval for renovascular
disease
Follow serum creatinine-does it
remain stable(Fatehi amp Chi-yuan 2016)
POSSIBLE INVESTIGATIONShellip
Acute interstitial nephritisbull Drugs are the most common cause of AIN
DIABETIC NEPHROPATHY 1 CAUSE OF CKDbull Clinical syndromebull Albuminuria gt30 mg 24 hrsbull Proteinuria gt500 mg24 hrsbull Hypertension developsbull Progressive increase in proteinuriabull Progressive decline in glomerular filtration rate
bull Chronic kidney disease should be attributed to diabetic nephropathies in most patients with diabetes if albuminuria and diabetic retinopathy are both present other causes of CKD should be entertained if diabetic retinopathy is absent (KDIGO 2007)
DIABETIC NEPHROPATHY MORTALITY
bull After 40 yrs of DM
bull 10 alive if proteinuria is present
bull 70 alive if proteinuria is absent
bull Heart Disease is 15 times higher risk in those with proteinuria
bull Proteinuria = death in this population
Dunkler et al 2015
GOALS OF CARE IN CKD GLUCOSE CONTROL
bull Target HbA1c ~70 (lt695 greatest chance of reducing albuminuria)bull Can be extended above 70 with comorbidities or limited life expectancy and
risk of hypoglycemiabull Risk of hypoglycemia increases as kidney function becomes impairedbull Declining kidney function may necessitate changes to diabetes medications and
bull Just having HTN can cause proteinuriabull Usually 1-2 gms of protein a daybull Treat them like a diabetic with ACEI or ARBS and tight blood
pressure controlbull JNC-8 goal lt14090 for ptrsquos with CKDbull National kidney foundation lt14090 if ckd and no proteinuria
lt13080 if proteinuria present
(James Ortiz amp Et Al 2014)
TREATING HYPERTENSIONPROTEINURIA ACEI ORARBbull Riskbenefit should be carefully assessed in the elderly and medically fragilebull Check labs after initiation
bull If less than 30 SCr increase continue and monitorbull If more than 30 SCr increase stop ACEi and evaluate for renal artery stenosis
bull Continue until contraindication arises no absolute eGFR cutoffbull Better proteinuria suppression with low Na diet and diureticsbull Avoid volume depletionbull Avoid ACEi and ARB in combination12
bull Risk of adverse events (impaired kidney function hyperkalemia)
(Kunz Friedrich Wolbers amp Mann 2008)(Mann Schmieder amp McQueen 2008)
bull In adults gt50 yrs statin when eGFR ge 60 mlmin173m2 statin or statinezetimibe combination when eGFR lt 60 mlmin173m2
bull In adults lt 50 yrs statin if history of known CAD MI DM strokebull Aspirin is indicated for secondary but not primary prevention
Kidney Disease Improving Global Outcomes (KDIGO) CKD Work Group Kidney Int Suppls 201331-150
STATINS-RENOPROTECTIVECONTROVERSY
bull HMG-CoA reductase inhibitors (statins) in high doses can cause proteinuria
bull Possibly associated with less inflammation endothelial dysfunction and scarring in the kidney because they also block inflammatory cytokines
bull Use statins for CV disease not to treat proteinuria
(Afzali and Goldsmith 2016)
MEDICINE CAUTION
bull Hold metformin when gfr lt35 mlmin
bull GFR lt50 mlmin should alert to check all doses of meds
bull No bisphosphanates lt35 mlmin
bull No NSAIDScox 2 inhibitors lt60 mlmin
bull Atenolol ndashrenal excretion
bull BACTRIM A lot of AKI
MEDICINE CAUTION
bull Lovenox-use subcut heparinbull Apixibanbull Dabigatranbull Rivaroxibanbull Lithiumbull GABAPENTIN (ckd 4 max 300mg qd ckd 5 max 300mg qod)
STEPS TO CKD PATIENT CARE
1 CKD definition and risks2 Assess GFR albuminuria3 Determine etiology4 Assess for evidence of progression5 Assess for associated complications6 Discuss dialysistransplantation
CKD-CVD-DIABETES LINK CKD IS A DISEASE MULTIPLIER
National kidney foundation 2014
KDIGO 2017
CKD-MINERAL BONE DISORDERS
bull As kidneys fail they
bull Stop activating calcitriol (the active form of Vit D)mdashcausing calcium imbalance
bull Do not remove phosphorus from bloodmdashleading to phosphorus retention
bull The extra phosphorus pulls calcium out of bones causing them to weaken
bull High phosphorus stimulates PTH release
bull These changes (plus others) cause the start of secondary hyperparathyroidism
bull Labs
bull eGFR
bull Calcium
bull Phos
bull Vit D
bull iPTH
(Qunibi amp Henrich 2017)
PREVALENCE OF ABNORMALITIES OF MINERAL METABOLISM PTH IN CKD
bull Progression of disease ndash declining eGFR increasing proteinuria
bull Degree of proteinuria nephrotic syndrome gt 05-10 gd on ACEi or ARB therapy
bull Etiology of CKD not certain
bull Need help with disease management
bull Indications for kidney biopsy
Rosenberg 2016
WHEN TO REFER
STEPS TO CKD PATIENT CARE
1 CKD definition and risks2 Assess GFR albuminuria3 Determine etiology4 Assess for evidence of progression5 Assess for associated complications6 Discuss dialysistransplantation
KIDNEY TRANSPLANTATION
bull Treatment of choice for ESRDbull Improves quality of lifebull Waiting list time varies-3-5 yearsbull 3 year survival rate after transplantation is 83-94bull Increased risk of cancer
STARTING DIALYSIS IN THE ELDERLYhellipOR NOT
bull Among patients gt 75 yrs with stage 5 CKD who chose to NOT start dialysisbull Overall more likely to die over next 1-2 years bull But if they had ischemic heart disease or other significant comorbidity NO
DIFFERENCE in survival
bull Active disease management and supportive care may be appropriate without starting dialysis in the ill elderly
bull Palliative care does not mean ldquono carerdquo
bull Must have end-of-life discussions
(Murtagh et al 2007)
CKD MANAGEMENTbull Diagnose cause and treat underlying conditionbull Stage per guidelinesbull Slow progression of kidney disease (ACE inhibitors)bull Monitor for complicationsmdashvolume overload hyperkalemia metabolic acidosis
hyperphosphatemia anorexia fatigue htn bone diseasebull Labs cmp cbc phos Vit D 25OH iPTH urine microscopy uric acid urine
proteincr ratio-frequency based off heat map Get sono at least oncebull Vaccinate influenza hep B pneumococcalbull Eval ASCVD risk-likely needs statinbull Possible dexa (donrsquot give bisphosphonates if GFRlt35 let specialist manage)bull Refer to nephrology when eGFR is lt30 (sometimes if higher risk-refer earlier)
CASE 1
bull 55 year old man with past medical history of headaches presents to your office for his first time visit to a PCP in over 30 years
bull He has no past history of being admitted to the hospital and he does not take any OTC medsNSAIDsherbal meds He has no history of ETOH abuse smoking or drug use
bull Vitals BP 180100 mmHg pulse 80 R 18
bull Exam No JVD S1S2 regular PMI shifted to the left no gallop no abdominal bruit pulses bilaterally equal and regular no leg edema
bull What would you order
bull EKG cbc cmp ua urine proteincr ratio lipid
LAB RESULTS
bull Labs reveal a creatinine of 22 mgdL eGFR 33 Urine shows no blood or casts Urineprotein ratio shows 1 gm protein24 hrs EKG shows LVH
bull Next step in workupbull Renal ultrasound 1st then SPEP UPEP with immunofixation serum free light chains
bull Additional labs neg Renal ultrasound shows that both kidneys are slightly reduced in size and are mildly echogenic with no mass or hydronephrosis
bull What is your diagnosis
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileMain_complications_of_persistent_high_blood_pressurepngCreative Commons License associated httpcreativecommonsorglicensesby-sa30
bull 3 months Howevermdashwe have evidence of structural abnormalities Could potentially stage at G3b A3 (red on the heat map)
bull Goal blood pressure
bull JNC 8 14090 NKF 13080
bull Additional lab needed for progression monitoring
bull Cbc renal panel phos Vit D iPTH uric acid urine micro (we already have the renal sono and urine proteincr ratio and lipid)
Selective renal angiography (left lower renal artery) after successful percutaneous balloon dilatation of the stenotic lesionFibromuscular dysplasia in an accessory renal artery causing renovascular hypertension
Secondary Hypertension
Images retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileRenal_FMD2jpg and httpcommonswikimediaorgwikiFileRenal_FMDjpgCreative Commons License associated httpcreativecommonsorglicensesby20deeden (both images)
CASE 2bull OS is a 64year old Hispanic female in for DM check She has had DM for 15+ years and is currently
taking metformin 1000mg bid Lisinopril 10mg a day atorvastatin 40mg a day Labs today showed the following
bull Hgba1c 86 cmp eGFR 50 lipid WNL proteincr ratio 650mg These results are similar to her last visit
bull Upon further hx-you find that she had a recent eye exam and has mild nonproliferaive retinopathy She does not have neuropathy or other ss
bull What further workup do you need
bull Renal sonogram urine micro iPTH vit D (25 OH) phos uric acid
bull Dx stage
bull G3a A3
bull What further treatment do you need
bull Improve glycemic control Increase Lisinopril to 20mg with a goal of 40mg Avoid NSAIDs or other nephrotoxic agents make sure meds are renally dosed monitor 3xyear nephro referral
MANAGEMENT OF CKD IN DIABETESeGFR Recommended
All patients
Yearly measurement of creatinine urinary albumin excretion potassium
45-60 Referral to a nephrologist if possibility for nondiabetickidney disease existsConsider dose adjustment of medicationsMonitor eGFR every 6 monthsMonitor electrolytes bicarbonate hemoglobin calcium phosphorus parathyroid hormone at least yearly
Assure vitamin D sufficiencyConsider bone density testingReferral for dietary counselling
American Diabetes Association Standards of Medical Care in Diabetes Microvascular complications and foot care Diabetes Care 2017 40 (Suppl 1) S88-S98
CASE 3
bull 19 year old African American woman presents to your clinic with complaints of fatigue joint pains a new rash on her face oral ulcer
bull On exam BP 15080 P 88 Afebrile 96 O2 sats on RAbull GEN No respiratory distress at restbull HEENT painless oral ulcer flat rash over malar eminences sparing the nasolabial fold pallor +bull Lungs CTAbull CVS S1S2 regularbull Abdomen soft NTbull Ext left elbow joint and bilateral wrist joints are swollen and tender
bull What would you orderbull CBC CMP ua urine microscopy (microalbumin or urine proteincr ratio) ANA esr RF anti-ccp uric acid TSH
CASE 3
bull Working dx fatigue oral ulcer joint pain
bull Basic Labs Na 135 K 55 Bicarb 18 BUN 50 Cr 35 eGFR 22 Ca 90 ANA + titer 1640
bull UA 3+ blood 3+ protein RBC casts +
bull Given these results what is the most likely diagnosis
bull What would you do
SYSTEMIC LUPUS ERYTHEMATOSUS (SLE)
bull SLE multisystemic disease Etiology unknown
bull Production of autoantibodies and immune complexes formation
bull There is renal involvement in the great majority of patients with SLE at some time of the evolution 66-90
SLE ndash LUPUS NEPHRITIS
bull Race SLE is more commonsevere in African americans than Caucasiansbull
bull Gender female-to-male ratio of 91
bull Age Most patients develop lupus nephritis early in their disease course SLE is more common among women in the third decade of life and lupus nephritis occurs in patients aged 20-40 years
bull Kidney Biopsy For staging lupus nephritis (Class 1-5)
CASE 5bull A 80 year old man who has not seen a PCP in many years
presents to your clinic for weakness for the past few months On further questioning he tells you that his bones also have been hurting lately and he has developed leg swelling in the past month or so
bull On exam bull BP 16090 P 88 Afebrilebull GEN Thin built manbull HEENT pallor presentbull Lungs clearbull CVS S1S2 regular no rub or gallopbull Abdomen soft NTbull Ext 2 + edema
CASE 5
bull Differentials
bull CHF MI Cancer arthritis
bull Labs
bull CBC CMP urine microscopy urine proteincr ratio ESR TSH EKG BNP pa and lat CXR
bull LABS Urine dipstick negative for protein or blood
bull Basic chem bull Na 136 (135-145) K 51 (35-55) Chloride 108 (96-106) Bicarb 25
Given this presentation and the labs (low anion gap and elevated calcium anemia kidney failure) what will you think of What will you order next
Serum and urine protein electrophoresis
Intratubular refractile casts with surrounding syncytial giant cell reaction with chronic tubulointerstitial nephritis and fibrosis characteristic of myeloma cast nephropathy
Kidney Biopsy
CASE STUDYbull A 35 year old African American woman was seen in the clinic for
chronic cough and dyspnea on exertion She gave history of vague symptoms of fatigue and weight loss of 20 Ibs over the last six months
bull List some differentialsbull TB sarcoid lupus thyroid problems PEbull What would you orderbull PPD cbc cmp UA TSH ANA pa and lat cxr
bull Her labs were significant for mildly elevated calcium level and a creatinine of 20 mgdL eGFR 37
bull She had 750 mg of proteinuriaday
bull PPD neg ANA neg TSH and other labs WNL
bull Assuming this is present more than 3 monthshelliphellipwhat is her ckd stage
bull G3b A3
bull What do we still need
CT scan of chest
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileAnterior_mediastinal_mass_thymomajpgCreative Commons License associated httpcreativecommonsorglicensesby20deeden
CXR ndash HILAR LYMPHADENOPATHY
WHATS NEEDED NEXT
bull Biopsy of hilar lymphadenopathy or renal biopsy
bull DX sarcoidosis
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileSarcoidosis_signs_and_symptomsjpgThis work is in the public domain in the United States because it is a work of the United States Federal Government under the terms of Title 17 Chapter 1 Section 105 of the US Code
NEWLY DX CKD
bull 1) urinalysis microscopy ultrasound proteincr ratio
bull If obstruction-treat
bull No obstruction
bull Hx critical (consider myeloma if high risk)
bull glomerular bleeding or albumin in urine
bull Yes workup for glomerular causes (ANArf hep B C upep spep ANCA complement C3 C4)
bull No sterile pyruria-consider interstitial nephritis
bull High risk renovascular disease Evaluate renovascular disease
Additional Online Resources for CKD LearningbullNational Kidney Foundation wwwkidneyorgbullUnited States Renal Data Service wwwusrdsorgbullCDCrsquos CKD Surveillance Project
httpnccdcdcgovckdbullNational Kidney Disease Education Program
(NKDEP) httpnkdepnihgov
BIBLIOGRAPHY
bull Afzali B amp Goldsmith D J (2016 June 29) Statins and chronic kidney disease (G C Curhan amp A M Sheridan Eds) Retrieved 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsstatins-and-chronic-kidney-disease
bull American Diabetes Association Standards of Medical Care in Diabetes (2017) Microvascular complications and foot care Diabetes Care 2017 (40) S88-S98
bull American Diabetes Association Standards of Medical Care in Diabetes (2017) Microvascular complications and foot care Diabetes Care 40 (suppl 1) S88-S98
bull Berns J S (2017 Mar 22) Treatment of anemia in nondialysis chronic kidney disease (T A Golper amp A M Sheridan Eds) Retrieved from UpToDate httpswww-uptodate-comproxywichitaeducontentstreatment-of-anemia-in-nondialysis-chronic-kidney-disease
bull Chan M Dall A T Fletcher K E Lu N amp Trivedi H (2007) Outcomes in patients with chronic kidney disease referred late to nephrologists a meta-analysis American Journal of Medicine 120(12) 1063-1070
bull Coresh J Selvin E amp Stevens L A (2007) Prevalence of chronic kidny disease in the United States JAMA 298(17) doi101001jama298172038
bull de Brito-Ashurst I Varagunam M Raftery M amp Yagoob M (2009) Bicarbonate supplementation slows progression of CKD and improves nutritional status Journal of American Society of Nephrology (20) 2075-2084
BIBLIOGRAPHY
bull Duncan L Heathcoat J Djurdjev O amp Levin A (2001) Screening for renal disease using serum creatinine who are we missing Nephrology Dialysis and Transplant 16(5) 1042-1046
bull Dunkler D Gao P Lee S F Heinz G Clase C M Tobe S Oberbauer R (2015 August 7) Risk prediction for early CKD in type 2 diabetes Retrieved from Clinical Journal of the American Society of Nephrology httpcjasnasnjournalsorgcontent1081371fullsid=61422554-a5f1-41ac-b696-dcd3b12bd268
bull Fatehi P amp Chi-yuan H (September 15 2016) Diagnostic approach to the patient with newly identified chronic kidney disease (G C Curhan amp A M Sheridan Eds) Retrieved May 7 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsdiagnostic-approach-to-the-patient-with-newly-identified-chronic-kidney-disease
bull Fink J e (2009) Chronic Kidney Disease as an Under-Recognized Threat to Patient Safety American journal of kidney diseases the official journal of the National Kidney Foundation 53(4) 681-688
bull Gaffo A L amp Saag K G (2008 Nov) Management of hyperuricemia and gout in CKD doihttpdxdoiorg101053jajkd200807035
bull Hebert L A amp Parikh S V (2014 June 18) Differential diagnosis and evaluation of glomerular disease (R J Glassock amp A Q Lam Eds) Retrieved May 7 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsdifferential-diagnosis-and-evaluation-of-glomerular-disease
bull Inker L Perrone R D Sterns R H amp Forman J P (2017 March 7) Assessment of kidney function Retrieved from UpToDate httpswww-uptodate-comproxywichitaeducontentsassessment-of-kidney-functionsource=search_resultampsearch=creatinineampselectedTitle=1~150
BIBLIOGRAPHY
bull James P A Ortiz E amp Et Al (2014) Evidence based guideline for the management of high blood pressure in adults (JNC) JAMA 311(5) 507-520
bull Kidney Disease Improving Global Outcomes (KDIGO) CKD Work Group (2013 January) KDIGO 2012 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease Retrieved from Kidney International Supplement httpwwwkidney-internationalorg
bull Kunz R Friedrich C Wolbers M amp Mann J F (2008) Meta-analysis effect of monotherapy and combination therapy with inhibitors of the renin angiotensin system on proteinuria in renal disease Annals of Internal Medicine 148(1) 30-48
bull Levey A Stevens L A Schmid C H Castro A F Feldman H I Kusek J W Coresh J (2009) A new equation to estimate glomerular filtration rate Annals of Internal Medicine 150(9) 604-612
bull Levin A Bakris G L Molitch M Smulders M M Williams L A amp Andress D L (2007 Jan) Prevalence of abnormal serum vitamin D PTH calcium and phosphorus in patients with chronic kidney disease results of the study to evaluate early kidney disease Kidney International 71(1) 31-38 Retrieved from PubMED
bull Mahajan A Simoni J Sheather S Broglio K Rajab M amp Wesson D (2010) Daily oral sodium bicarbonate preserves glomerular filtration rate by slowing its decline in early hypertensive nephropathy Kidney International (78_ 303-309
bull Mann J Schmieder R E amp McQueen M (2008) Renal outcomes with telmisartan ramipril or both in people at high vascular risk (the ONTARGET study) a multicentre randomised doubleblind ocntrolled trial Lancet 372(9638) 547-533
BIBLIOGRAPHY
bull Matovinović M S (2009) Pathophysiology and classification of kidney disease Retrieved from The Journal of the International Federation of Clinical Chemistry and Laboratory Medicine httpwwwifccorgifccfilesdocs20010902pdf
bull Moe S Drueke T Lameire N amp Eknoyan G (2007 Jan) Chronic kidney disease-mineral-bone disorder a new paradigmdoi101053jackd200610005
bull Murtagh F E Marsh J E Donohoe P Ekbal N J Sheerin N S amp Harris F E (2007 July) Dialysis or not A comparative survival study of patients over 75 years with chronic kidney disease stage 5 Retrieved from Nephrology Dialysis and Transplant 22(7) httpswwwncbinlmnihgovpubmed17412702
bull National Kidney Foundation (2002) KDOQI clinical practice guidelines for chronic kidney disease evaluation classification andstratification American Journal of Kidney Disease S1-S266
bull National Kidney Foundation (2014 November 5) Fact Sheets Retrieved from httpwwwkidneyorgnewsnewsroomfactsheetsFastFacts
bull Pal S (2012 June 2) Trends in chronic kidney disease Retrieved from US Pharmacist (37)6 httpswwwuspharmacistcomarticletrends-in-chronic-kidney-disease
bull Qunibi W amp Henrich W L (2017 Jan 19) Overview of chronic kidney disease-mineral and bone disorder (J Berns amp A M Sheridan Eds) Retrieved from UpToDate httpswww-uptodate-comoverview-of-chronic-kidney-disease-mineral-and-bone-disorder-ckd-mbd
bull Rosenberg M (2016 Feb 24) Overview of the management of chronic kidney disease in adults (G C Curhan amp A M Sheridan Eds) Retrieved from UpToDate UpToDate httpswww-uptodate-comproxywichitaeducontentsoverview-of-the-management-of-chronic-kidney-disease-in-adults
BIBLIOGRAPHY
bull Szczech L Stewart R C Hsu-Lin S DeLosky R J Astor B C Fox C H Vassalotti J A (2014) Primary care detection of chronic kidney disease in adults with type 2 diabetes The ADD-CKD Study (Awareness Detection and Drug Therapy in type 2 diabetes and chronic kidney disease PLOS doihttpsdoiorg101371journalpone0110535
bull USRDS (2016) Annual data report 2016 Epidemiology of kidney disease in the United States Retrieved from United States Renal Data System httpswwwusrdsorgadraspx
bull Vasudev B amp Vasudev M (2012) A model curriculum for residents rotating in nephrology MedEDPORTAL doihttpdoiorg1015766mep_2374-82658288
bull Wei L MacDonald T M Jennings C Sheng X amp Flynn R W (2013) Estimated GFR reporting is associated with decreased nonsteroidal anti-inflammatory drug prescribing and increased renal function Kidney International (84)1 174-178
chronic kidney disease in primary care
CKD as a Public Health Issue
Slide Number 3
Costs of CKD in 2013 dollarsUSRDS report
Steps to CKD Patient Care
Renal anatomy and physiology
Definition of Chronic Kidney Disease
CKD Risk Factors
Gaps in CKD Diagnosis
Slide Number 10
Steps to CKD Patient Care
creatinine
Glomerular filtration rate
Slide Number 14
Slide Number 15
Use These Equations Cautiously if at all in hellip
lab albumin creatinine ratio
The New CKD Categories
Steps to CKD Patient Care
Slide Number 20
Kidney Involvement in Systemic Diseases
Slide Number 22
Slide Number 23
DysmorphicRenal Hematuria
Slide Number 25
If you have albuminuria or hematuria-order the following labs
Prevalence of Abnormalities of Mineral Metabolism PTH in CKD
Managing CKD-MBD complications
CKD-MBD Testing
Anemia Becomes More Common as Kidney Function Declines
Detect and Manage CKD Complications
Complications-metabolic acidosis
Complications-vascular calcification
Hyperkalemia management
Hyperuricemia levels amp CKD
CKD monitoring levels 345
Slide Number 59
When to Refer to a Nephrologist
When to Refer
Steps to CKD Patient Care
Kidney transplantation
Starting Dialysis in the ElderlyhellipOr Not
Ckd management
Case 1
Slide Number 67
Lab results
Slide Number 69
Hypertensive nephropathy with proteinuria
Slide Number 71
Case 2
Slide Number 73
Management of CKD in Diabetes
Case 3
Case 3
Systemic Lupus Erythematosus (SLE)
SLE ndash Lupus Nephritis
Case 5
Case 5
Slide Number 81
Slide Number 82
Case study
Slide Number 84
CXR ndash Hilar Lymphadenopathy
Whats needed next
Slide Number 87
newly dx ckd
Slide Number 89
Bibliography
bibliography
bibliography
bibliography
bibliography
Stage 12
Stage 3
Stage 4
Stage 5
Hb le10 gdL
52
56
11
272
Hb gt10-le12 gdL
216
359
426
483
Hb le12 gdL
267
416
536
755
Stage 12
Stage 3
Stage 4
Stage 5
IF YOU HAVE ALBUMINURIA OR HEMATURIA-ORDER THE FOLLOWING LABS
Tests of autoimmunity Hepatitis serologies gt40 years- paraproteinassessment
ANA Hepatitis B serology (HBsAG)
Serum protein electrophoresis (SPEP)
RFanti-ccp Hepatitis C serology(HCV antibody)
Urine protein electrophoresis (UPEP)
Complement C3 C4
ANCANational Kidney Disease Education Program 2014 NIH
UPTODATE LAB RECOMENDATIONS
bull Lab to order cbc cmp urine albumincr ratio urine microscopy
bull Nephrotic pattern (protein gt35gday) ANA anti DS DNA C3 and C4 antibodies HIV HBV HCV serumurine immunofixation (amyloidosis) free light chain analysis (light chain deposition disease)
bull Nephritic pattern (red cells white cells casts variable protein) C3 C4 ANA dsDNA antineutrophil cytoplasmic antibody (ANCA) titers a streptozyme test HBV and HCV serologies HIV and in some cases blood cultures anti-glomerular basement membrane (GBM) antibodies and cryoglobulins
bull Renal biopsy(Hebert amp Parikh 2014)
EVALUATION OF NEW CKDNO OBSTRUCTION
NO EVIDENCE OF GLOMERULAR BLEEDING
High risk for multmyeloma (gt40
no nsaids no contrast
SPEP UPEP with immunofixation serum free light
chains
Evaluation depends on UA
Sterile pyuria
Eval for interstitial nephritis
Normal urinalysis
High risk for renovascular
disease
Eval for renovascular
disease
Follow serum creatinine-does it
remain stable(Fatehi amp Chi-yuan 2016)
POSSIBLE INVESTIGATIONShellip
Acute interstitial nephritisbull Drugs are the most common cause of AIN
DIABETIC NEPHROPATHY 1 CAUSE OF CKDbull Clinical syndromebull Albuminuria gt30 mg 24 hrsbull Proteinuria gt500 mg24 hrsbull Hypertension developsbull Progressive increase in proteinuriabull Progressive decline in glomerular filtration rate
bull Chronic kidney disease should be attributed to diabetic nephropathies in most patients with diabetes if albuminuria and diabetic retinopathy are both present other causes of CKD should be entertained if diabetic retinopathy is absent (KDIGO 2007)
DIABETIC NEPHROPATHY MORTALITY
bull After 40 yrs of DM
bull 10 alive if proteinuria is present
bull 70 alive if proteinuria is absent
bull Heart Disease is 15 times higher risk in those with proteinuria
bull Proteinuria = death in this population
Dunkler et al 2015
GOALS OF CARE IN CKD GLUCOSE CONTROL
bull Target HbA1c ~70 (lt695 greatest chance of reducing albuminuria)bull Can be extended above 70 with comorbidities or limited life expectancy and
risk of hypoglycemiabull Risk of hypoglycemia increases as kidney function becomes impairedbull Declining kidney function may necessitate changes to diabetes medications and
bull Just having HTN can cause proteinuriabull Usually 1-2 gms of protein a daybull Treat them like a diabetic with ACEI or ARBS and tight blood
pressure controlbull JNC-8 goal lt14090 for ptrsquos with CKDbull National kidney foundation lt14090 if ckd and no proteinuria
lt13080 if proteinuria present
(James Ortiz amp Et Al 2014)
TREATING HYPERTENSIONPROTEINURIA ACEI ORARBbull Riskbenefit should be carefully assessed in the elderly and medically fragilebull Check labs after initiation
bull If less than 30 SCr increase continue and monitorbull If more than 30 SCr increase stop ACEi and evaluate for renal artery stenosis
bull Continue until contraindication arises no absolute eGFR cutoffbull Better proteinuria suppression with low Na diet and diureticsbull Avoid volume depletionbull Avoid ACEi and ARB in combination12
bull Risk of adverse events (impaired kidney function hyperkalemia)
(Kunz Friedrich Wolbers amp Mann 2008)(Mann Schmieder amp McQueen 2008)
bull In adults gt50 yrs statin when eGFR ge 60 mlmin173m2 statin or statinezetimibe combination when eGFR lt 60 mlmin173m2
bull In adults lt 50 yrs statin if history of known CAD MI DM strokebull Aspirin is indicated for secondary but not primary prevention
Kidney Disease Improving Global Outcomes (KDIGO) CKD Work Group Kidney Int Suppls 201331-150
STATINS-RENOPROTECTIVECONTROVERSY
bull HMG-CoA reductase inhibitors (statins) in high doses can cause proteinuria
bull Possibly associated with less inflammation endothelial dysfunction and scarring in the kidney because they also block inflammatory cytokines
bull Use statins for CV disease not to treat proteinuria
(Afzali and Goldsmith 2016)
MEDICINE CAUTION
bull Hold metformin when gfr lt35 mlmin
bull GFR lt50 mlmin should alert to check all doses of meds
bull No bisphosphanates lt35 mlmin
bull No NSAIDScox 2 inhibitors lt60 mlmin
bull Atenolol ndashrenal excretion
bull BACTRIM A lot of AKI
MEDICINE CAUTION
bull Lovenox-use subcut heparinbull Apixibanbull Dabigatranbull Rivaroxibanbull Lithiumbull GABAPENTIN (ckd 4 max 300mg qd ckd 5 max 300mg qod)
STEPS TO CKD PATIENT CARE
1 CKD definition and risks2 Assess GFR albuminuria3 Determine etiology4 Assess for evidence of progression5 Assess for associated complications6 Discuss dialysistransplantation
CKD-CVD-DIABETES LINK CKD IS A DISEASE MULTIPLIER
National kidney foundation 2014
KDIGO 2017
CKD-MINERAL BONE DISORDERS
bull As kidneys fail they
bull Stop activating calcitriol (the active form of Vit D)mdashcausing calcium imbalance
bull Do not remove phosphorus from bloodmdashleading to phosphorus retention
bull The extra phosphorus pulls calcium out of bones causing them to weaken
bull High phosphorus stimulates PTH release
bull These changes (plus others) cause the start of secondary hyperparathyroidism
bull Labs
bull eGFR
bull Calcium
bull Phos
bull Vit D
bull iPTH
(Qunibi amp Henrich 2017)
PREVALENCE OF ABNORMALITIES OF MINERAL METABOLISM PTH IN CKD
bull Progression of disease ndash declining eGFR increasing proteinuria
bull Degree of proteinuria nephrotic syndrome gt 05-10 gd on ACEi or ARB therapy
bull Etiology of CKD not certain
bull Need help with disease management
bull Indications for kidney biopsy
Rosenberg 2016
WHEN TO REFER
STEPS TO CKD PATIENT CARE
1 CKD definition and risks2 Assess GFR albuminuria3 Determine etiology4 Assess for evidence of progression5 Assess for associated complications6 Discuss dialysistransplantation
KIDNEY TRANSPLANTATION
bull Treatment of choice for ESRDbull Improves quality of lifebull Waiting list time varies-3-5 yearsbull 3 year survival rate after transplantation is 83-94bull Increased risk of cancer
STARTING DIALYSIS IN THE ELDERLYhellipOR NOT
bull Among patients gt 75 yrs with stage 5 CKD who chose to NOT start dialysisbull Overall more likely to die over next 1-2 years bull But if they had ischemic heart disease or other significant comorbidity NO
DIFFERENCE in survival
bull Active disease management and supportive care may be appropriate without starting dialysis in the ill elderly
bull Palliative care does not mean ldquono carerdquo
bull Must have end-of-life discussions
(Murtagh et al 2007)
CKD MANAGEMENTbull Diagnose cause and treat underlying conditionbull Stage per guidelinesbull Slow progression of kidney disease (ACE inhibitors)bull Monitor for complicationsmdashvolume overload hyperkalemia metabolic acidosis
hyperphosphatemia anorexia fatigue htn bone diseasebull Labs cmp cbc phos Vit D 25OH iPTH urine microscopy uric acid urine
proteincr ratio-frequency based off heat map Get sono at least oncebull Vaccinate influenza hep B pneumococcalbull Eval ASCVD risk-likely needs statinbull Possible dexa (donrsquot give bisphosphonates if GFRlt35 let specialist manage)bull Refer to nephrology when eGFR is lt30 (sometimes if higher risk-refer earlier)
CASE 1
bull 55 year old man with past medical history of headaches presents to your office for his first time visit to a PCP in over 30 years
bull He has no past history of being admitted to the hospital and he does not take any OTC medsNSAIDsherbal meds He has no history of ETOH abuse smoking or drug use
bull Vitals BP 180100 mmHg pulse 80 R 18
bull Exam No JVD S1S2 regular PMI shifted to the left no gallop no abdominal bruit pulses bilaterally equal and regular no leg edema
bull What would you order
bull EKG cbc cmp ua urine proteincr ratio lipid
LAB RESULTS
bull Labs reveal a creatinine of 22 mgdL eGFR 33 Urine shows no blood or casts Urineprotein ratio shows 1 gm protein24 hrs EKG shows LVH
bull Next step in workupbull Renal ultrasound 1st then SPEP UPEP with immunofixation serum free light chains
bull Additional labs neg Renal ultrasound shows that both kidneys are slightly reduced in size and are mildly echogenic with no mass or hydronephrosis
bull What is your diagnosis
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileMain_complications_of_persistent_high_blood_pressurepngCreative Commons License associated httpcreativecommonsorglicensesby-sa30
bull 3 months Howevermdashwe have evidence of structural abnormalities Could potentially stage at G3b A3 (red on the heat map)
bull Goal blood pressure
bull JNC 8 14090 NKF 13080
bull Additional lab needed for progression monitoring
bull Cbc renal panel phos Vit D iPTH uric acid urine micro (we already have the renal sono and urine proteincr ratio and lipid)
Selective renal angiography (left lower renal artery) after successful percutaneous balloon dilatation of the stenotic lesionFibromuscular dysplasia in an accessory renal artery causing renovascular hypertension
Secondary Hypertension
Images retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileRenal_FMD2jpg and httpcommonswikimediaorgwikiFileRenal_FMDjpgCreative Commons License associated httpcreativecommonsorglicensesby20deeden (both images)
CASE 2bull OS is a 64year old Hispanic female in for DM check She has had DM for 15+ years and is currently
taking metformin 1000mg bid Lisinopril 10mg a day atorvastatin 40mg a day Labs today showed the following
bull Hgba1c 86 cmp eGFR 50 lipid WNL proteincr ratio 650mg These results are similar to her last visit
bull Upon further hx-you find that she had a recent eye exam and has mild nonproliferaive retinopathy She does not have neuropathy or other ss
bull What further workup do you need
bull Renal sonogram urine micro iPTH vit D (25 OH) phos uric acid
bull Dx stage
bull G3a A3
bull What further treatment do you need
bull Improve glycemic control Increase Lisinopril to 20mg with a goal of 40mg Avoid NSAIDs or other nephrotoxic agents make sure meds are renally dosed monitor 3xyear nephro referral
MANAGEMENT OF CKD IN DIABETESeGFR Recommended
All patients
Yearly measurement of creatinine urinary albumin excretion potassium
45-60 Referral to a nephrologist if possibility for nondiabetickidney disease existsConsider dose adjustment of medicationsMonitor eGFR every 6 monthsMonitor electrolytes bicarbonate hemoglobin calcium phosphorus parathyroid hormone at least yearly
Assure vitamin D sufficiencyConsider bone density testingReferral for dietary counselling
American Diabetes Association Standards of Medical Care in Diabetes Microvascular complications and foot care Diabetes Care 2017 40 (Suppl 1) S88-S98
CASE 3
bull 19 year old African American woman presents to your clinic with complaints of fatigue joint pains a new rash on her face oral ulcer
bull On exam BP 15080 P 88 Afebrile 96 O2 sats on RAbull GEN No respiratory distress at restbull HEENT painless oral ulcer flat rash over malar eminences sparing the nasolabial fold pallor +bull Lungs CTAbull CVS S1S2 regularbull Abdomen soft NTbull Ext left elbow joint and bilateral wrist joints are swollen and tender
bull What would you orderbull CBC CMP ua urine microscopy (microalbumin or urine proteincr ratio) ANA esr RF anti-ccp uric acid TSH
CASE 3
bull Working dx fatigue oral ulcer joint pain
bull Basic Labs Na 135 K 55 Bicarb 18 BUN 50 Cr 35 eGFR 22 Ca 90 ANA + titer 1640
bull UA 3+ blood 3+ protein RBC casts +
bull Given these results what is the most likely diagnosis
bull What would you do
SYSTEMIC LUPUS ERYTHEMATOSUS (SLE)
bull SLE multisystemic disease Etiology unknown
bull Production of autoantibodies and immune complexes formation
bull There is renal involvement in the great majority of patients with SLE at some time of the evolution 66-90
SLE ndash LUPUS NEPHRITIS
bull Race SLE is more commonsevere in African americans than Caucasiansbull
bull Gender female-to-male ratio of 91
bull Age Most patients develop lupus nephritis early in their disease course SLE is more common among women in the third decade of life and lupus nephritis occurs in patients aged 20-40 years
bull Kidney Biopsy For staging lupus nephritis (Class 1-5)
CASE 5bull A 80 year old man who has not seen a PCP in many years
presents to your clinic for weakness for the past few months On further questioning he tells you that his bones also have been hurting lately and he has developed leg swelling in the past month or so
bull On exam bull BP 16090 P 88 Afebrilebull GEN Thin built manbull HEENT pallor presentbull Lungs clearbull CVS S1S2 regular no rub or gallopbull Abdomen soft NTbull Ext 2 + edema
CASE 5
bull Differentials
bull CHF MI Cancer arthritis
bull Labs
bull CBC CMP urine microscopy urine proteincr ratio ESR TSH EKG BNP pa and lat CXR
bull LABS Urine dipstick negative for protein or blood
bull Basic chem bull Na 136 (135-145) K 51 (35-55) Chloride 108 (96-106) Bicarb 25
Given this presentation and the labs (low anion gap and elevated calcium anemia kidney failure) what will you think of What will you order next
Serum and urine protein electrophoresis
Intratubular refractile casts with surrounding syncytial giant cell reaction with chronic tubulointerstitial nephritis and fibrosis characteristic of myeloma cast nephropathy
Kidney Biopsy
CASE STUDYbull A 35 year old African American woman was seen in the clinic for
chronic cough and dyspnea on exertion She gave history of vague symptoms of fatigue and weight loss of 20 Ibs over the last six months
bull List some differentialsbull TB sarcoid lupus thyroid problems PEbull What would you orderbull PPD cbc cmp UA TSH ANA pa and lat cxr
bull Her labs were significant for mildly elevated calcium level and a creatinine of 20 mgdL eGFR 37
bull She had 750 mg of proteinuriaday
bull PPD neg ANA neg TSH and other labs WNL
bull Assuming this is present more than 3 monthshelliphellipwhat is her ckd stage
bull G3b A3
bull What do we still need
CT scan of chest
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileAnterior_mediastinal_mass_thymomajpgCreative Commons License associated httpcreativecommonsorglicensesby20deeden
CXR ndash HILAR LYMPHADENOPATHY
WHATS NEEDED NEXT
bull Biopsy of hilar lymphadenopathy or renal biopsy
bull DX sarcoidosis
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileSarcoidosis_signs_and_symptomsjpgThis work is in the public domain in the United States because it is a work of the United States Federal Government under the terms of Title 17 Chapter 1 Section 105 of the US Code
NEWLY DX CKD
bull 1) urinalysis microscopy ultrasound proteincr ratio
bull If obstruction-treat
bull No obstruction
bull Hx critical (consider myeloma if high risk)
bull glomerular bleeding or albumin in urine
bull Yes workup for glomerular causes (ANArf hep B C upep spep ANCA complement C3 C4)
bull No sterile pyruria-consider interstitial nephritis
bull High risk renovascular disease Evaluate renovascular disease
Additional Online Resources for CKD LearningbullNational Kidney Foundation wwwkidneyorgbullUnited States Renal Data Service wwwusrdsorgbullCDCrsquos CKD Surveillance Project
httpnccdcdcgovckdbullNational Kidney Disease Education Program
(NKDEP) httpnkdepnihgov
BIBLIOGRAPHY
bull Afzali B amp Goldsmith D J (2016 June 29) Statins and chronic kidney disease (G C Curhan amp A M Sheridan Eds) Retrieved 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsstatins-and-chronic-kidney-disease
bull American Diabetes Association Standards of Medical Care in Diabetes (2017) Microvascular complications and foot care Diabetes Care 2017 (40) S88-S98
bull American Diabetes Association Standards of Medical Care in Diabetes (2017) Microvascular complications and foot care Diabetes Care 40 (suppl 1) S88-S98
bull Berns J S (2017 Mar 22) Treatment of anemia in nondialysis chronic kidney disease (T A Golper amp A M Sheridan Eds) Retrieved from UpToDate httpswww-uptodate-comproxywichitaeducontentstreatment-of-anemia-in-nondialysis-chronic-kidney-disease
bull Chan M Dall A T Fletcher K E Lu N amp Trivedi H (2007) Outcomes in patients with chronic kidney disease referred late to nephrologists a meta-analysis American Journal of Medicine 120(12) 1063-1070
bull Coresh J Selvin E amp Stevens L A (2007) Prevalence of chronic kidny disease in the United States JAMA 298(17) doi101001jama298172038
bull de Brito-Ashurst I Varagunam M Raftery M amp Yagoob M (2009) Bicarbonate supplementation slows progression of CKD and improves nutritional status Journal of American Society of Nephrology (20) 2075-2084
BIBLIOGRAPHY
bull Duncan L Heathcoat J Djurdjev O amp Levin A (2001) Screening for renal disease using serum creatinine who are we missing Nephrology Dialysis and Transplant 16(5) 1042-1046
bull Dunkler D Gao P Lee S F Heinz G Clase C M Tobe S Oberbauer R (2015 August 7) Risk prediction for early CKD in type 2 diabetes Retrieved from Clinical Journal of the American Society of Nephrology httpcjasnasnjournalsorgcontent1081371fullsid=61422554-a5f1-41ac-b696-dcd3b12bd268
bull Fatehi P amp Chi-yuan H (September 15 2016) Diagnostic approach to the patient with newly identified chronic kidney disease (G C Curhan amp A M Sheridan Eds) Retrieved May 7 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsdiagnostic-approach-to-the-patient-with-newly-identified-chronic-kidney-disease
bull Fink J e (2009) Chronic Kidney Disease as an Under-Recognized Threat to Patient Safety American journal of kidney diseases the official journal of the National Kidney Foundation 53(4) 681-688
bull Gaffo A L amp Saag K G (2008 Nov) Management of hyperuricemia and gout in CKD doihttpdxdoiorg101053jajkd200807035
bull Hebert L A amp Parikh S V (2014 June 18) Differential diagnosis and evaluation of glomerular disease (R J Glassock amp A Q Lam Eds) Retrieved May 7 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsdifferential-diagnosis-and-evaluation-of-glomerular-disease
bull Inker L Perrone R D Sterns R H amp Forman J P (2017 March 7) Assessment of kidney function Retrieved from UpToDate httpswww-uptodate-comproxywichitaeducontentsassessment-of-kidney-functionsource=search_resultampsearch=creatinineampselectedTitle=1~150
BIBLIOGRAPHY
bull James P A Ortiz E amp Et Al (2014) Evidence based guideline for the management of high blood pressure in adults (JNC) JAMA 311(5) 507-520
bull Kidney Disease Improving Global Outcomes (KDIGO) CKD Work Group (2013 January) KDIGO 2012 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease Retrieved from Kidney International Supplement httpwwwkidney-internationalorg
bull Kunz R Friedrich C Wolbers M amp Mann J F (2008) Meta-analysis effect of monotherapy and combination therapy with inhibitors of the renin angiotensin system on proteinuria in renal disease Annals of Internal Medicine 148(1) 30-48
bull Levey A Stevens L A Schmid C H Castro A F Feldman H I Kusek J W Coresh J (2009) A new equation to estimate glomerular filtration rate Annals of Internal Medicine 150(9) 604-612
bull Levin A Bakris G L Molitch M Smulders M M Williams L A amp Andress D L (2007 Jan) Prevalence of abnormal serum vitamin D PTH calcium and phosphorus in patients with chronic kidney disease results of the study to evaluate early kidney disease Kidney International 71(1) 31-38 Retrieved from PubMED
bull Mahajan A Simoni J Sheather S Broglio K Rajab M amp Wesson D (2010) Daily oral sodium bicarbonate preserves glomerular filtration rate by slowing its decline in early hypertensive nephropathy Kidney International (78_ 303-309
bull Mann J Schmieder R E amp McQueen M (2008) Renal outcomes with telmisartan ramipril or both in people at high vascular risk (the ONTARGET study) a multicentre randomised doubleblind ocntrolled trial Lancet 372(9638) 547-533
BIBLIOGRAPHY
bull Matovinović M S (2009) Pathophysiology and classification of kidney disease Retrieved from The Journal of the International Federation of Clinical Chemistry and Laboratory Medicine httpwwwifccorgifccfilesdocs20010902pdf
bull Moe S Drueke T Lameire N amp Eknoyan G (2007 Jan) Chronic kidney disease-mineral-bone disorder a new paradigmdoi101053jackd200610005
bull Murtagh F E Marsh J E Donohoe P Ekbal N J Sheerin N S amp Harris F E (2007 July) Dialysis or not A comparative survival study of patients over 75 years with chronic kidney disease stage 5 Retrieved from Nephrology Dialysis and Transplant 22(7) httpswwwncbinlmnihgovpubmed17412702
bull National Kidney Foundation (2002) KDOQI clinical practice guidelines for chronic kidney disease evaluation classification andstratification American Journal of Kidney Disease S1-S266
bull National Kidney Foundation (2014 November 5) Fact Sheets Retrieved from httpwwwkidneyorgnewsnewsroomfactsheetsFastFacts
bull Pal S (2012 June 2) Trends in chronic kidney disease Retrieved from US Pharmacist (37)6 httpswwwuspharmacistcomarticletrends-in-chronic-kidney-disease
bull Qunibi W amp Henrich W L (2017 Jan 19) Overview of chronic kidney disease-mineral and bone disorder (J Berns amp A M Sheridan Eds) Retrieved from UpToDate httpswww-uptodate-comoverview-of-chronic-kidney-disease-mineral-and-bone-disorder-ckd-mbd
bull Rosenberg M (2016 Feb 24) Overview of the management of chronic kidney disease in adults (G C Curhan amp A M Sheridan Eds) Retrieved from UpToDate UpToDate httpswww-uptodate-comproxywichitaeducontentsoverview-of-the-management-of-chronic-kidney-disease-in-adults
BIBLIOGRAPHY
bull Szczech L Stewart R C Hsu-Lin S DeLosky R J Astor B C Fox C H Vassalotti J A (2014) Primary care detection of chronic kidney disease in adults with type 2 diabetes The ADD-CKD Study (Awareness Detection and Drug Therapy in type 2 diabetes and chronic kidney disease PLOS doihttpsdoiorg101371journalpone0110535
bull USRDS (2016) Annual data report 2016 Epidemiology of kidney disease in the United States Retrieved from United States Renal Data System httpswwwusrdsorgadraspx
bull Vasudev B amp Vasudev M (2012) A model curriculum for residents rotating in nephrology MedEDPORTAL doihttpdoiorg1015766mep_2374-82658288
bull Wei L MacDonald T M Jennings C Sheng X amp Flynn R W (2013) Estimated GFR reporting is associated with decreased nonsteroidal anti-inflammatory drug prescribing and increased renal function Kidney International (84)1 174-178
chronic kidney disease in primary care
CKD as a Public Health Issue
Slide Number 3
Costs of CKD in 2013 dollarsUSRDS report
Steps to CKD Patient Care
Renal anatomy and physiology
Definition of Chronic Kidney Disease
CKD Risk Factors
Gaps in CKD Diagnosis
Slide Number 10
Steps to CKD Patient Care
creatinine
Glomerular filtration rate
Slide Number 14
Slide Number 15
Use These Equations Cautiously if at all in hellip
lab albumin creatinine ratio
The New CKD Categories
Steps to CKD Patient Care
Slide Number 20
Kidney Involvement in Systemic Diseases
Slide Number 22
Slide Number 23
DysmorphicRenal Hematuria
Slide Number 25
If you have albuminuria or hematuria-order the following labs
Prevalence of Abnormalities of Mineral Metabolism PTH in CKD
Managing CKD-MBD complications
CKD-MBD Testing
Anemia Becomes More Common as Kidney Function Declines
Detect and Manage CKD Complications
Complications-metabolic acidosis
Complications-vascular calcification
Hyperkalemia management
Hyperuricemia levels amp CKD
CKD monitoring levels 345
Slide Number 59
When to Refer to a Nephrologist
When to Refer
Steps to CKD Patient Care
Kidney transplantation
Starting Dialysis in the ElderlyhellipOr Not
Ckd management
Case 1
Slide Number 67
Lab results
Slide Number 69
Hypertensive nephropathy with proteinuria
Slide Number 71
Case 2
Slide Number 73
Management of CKD in Diabetes
Case 3
Case 3
Systemic Lupus Erythematosus (SLE)
SLE ndash Lupus Nephritis
Case 5
Case 5
Slide Number 81
Slide Number 82
Case study
Slide Number 84
CXR ndash Hilar Lymphadenopathy
Whats needed next
Slide Number 87
newly dx ckd
Slide Number 89
Bibliography
bibliography
bibliography
bibliography
bibliography
Stage 12
Stage 3
Stage 4
Stage 5
Hb le10 gdL
52
56
11
272
Hb gt10-le12 gdL
216
359
426
483
Hb le12 gdL
267
416
536
755
Stage 12
Stage 3
Stage 4
Stage 5
UPTODATE LAB RECOMENDATIONS
bull Lab to order cbc cmp urine albumincr ratio urine microscopy
bull Nephrotic pattern (protein gt35gday) ANA anti DS DNA C3 and C4 antibodies HIV HBV HCV serumurine immunofixation (amyloidosis) free light chain analysis (light chain deposition disease)
bull Nephritic pattern (red cells white cells casts variable protein) C3 C4 ANA dsDNA antineutrophil cytoplasmic antibody (ANCA) titers a streptozyme test HBV and HCV serologies HIV and in some cases blood cultures anti-glomerular basement membrane (GBM) antibodies and cryoglobulins
bull Renal biopsy(Hebert amp Parikh 2014)
EVALUATION OF NEW CKDNO OBSTRUCTION
NO EVIDENCE OF GLOMERULAR BLEEDING
High risk for multmyeloma (gt40
no nsaids no contrast
SPEP UPEP with immunofixation serum free light
chains
Evaluation depends on UA
Sterile pyuria
Eval for interstitial nephritis
Normal urinalysis
High risk for renovascular
disease
Eval for renovascular
disease
Follow serum creatinine-does it
remain stable(Fatehi amp Chi-yuan 2016)
POSSIBLE INVESTIGATIONShellip
Acute interstitial nephritisbull Drugs are the most common cause of AIN
DIABETIC NEPHROPATHY 1 CAUSE OF CKDbull Clinical syndromebull Albuminuria gt30 mg 24 hrsbull Proteinuria gt500 mg24 hrsbull Hypertension developsbull Progressive increase in proteinuriabull Progressive decline in glomerular filtration rate
bull Chronic kidney disease should be attributed to diabetic nephropathies in most patients with diabetes if albuminuria and diabetic retinopathy are both present other causes of CKD should be entertained if diabetic retinopathy is absent (KDIGO 2007)
DIABETIC NEPHROPATHY MORTALITY
bull After 40 yrs of DM
bull 10 alive if proteinuria is present
bull 70 alive if proteinuria is absent
bull Heart Disease is 15 times higher risk in those with proteinuria
bull Proteinuria = death in this population
Dunkler et al 2015
GOALS OF CARE IN CKD GLUCOSE CONTROL
bull Target HbA1c ~70 (lt695 greatest chance of reducing albuminuria)bull Can be extended above 70 with comorbidities or limited life expectancy and
risk of hypoglycemiabull Risk of hypoglycemia increases as kidney function becomes impairedbull Declining kidney function may necessitate changes to diabetes medications and
bull Just having HTN can cause proteinuriabull Usually 1-2 gms of protein a daybull Treat them like a diabetic with ACEI or ARBS and tight blood
pressure controlbull JNC-8 goal lt14090 for ptrsquos with CKDbull National kidney foundation lt14090 if ckd and no proteinuria
lt13080 if proteinuria present
(James Ortiz amp Et Al 2014)
TREATING HYPERTENSIONPROTEINURIA ACEI ORARBbull Riskbenefit should be carefully assessed in the elderly and medically fragilebull Check labs after initiation
bull If less than 30 SCr increase continue and monitorbull If more than 30 SCr increase stop ACEi and evaluate for renal artery stenosis
bull Continue until contraindication arises no absolute eGFR cutoffbull Better proteinuria suppression with low Na diet and diureticsbull Avoid volume depletionbull Avoid ACEi and ARB in combination12
bull Risk of adverse events (impaired kidney function hyperkalemia)
(Kunz Friedrich Wolbers amp Mann 2008)(Mann Schmieder amp McQueen 2008)
bull In adults gt50 yrs statin when eGFR ge 60 mlmin173m2 statin or statinezetimibe combination when eGFR lt 60 mlmin173m2
bull In adults lt 50 yrs statin if history of known CAD MI DM strokebull Aspirin is indicated for secondary but not primary prevention
Kidney Disease Improving Global Outcomes (KDIGO) CKD Work Group Kidney Int Suppls 201331-150
STATINS-RENOPROTECTIVECONTROVERSY
bull HMG-CoA reductase inhibitors (statins) in high doses can cause proteinuria
bull Possibly associated with less inflammation endothelial dysfunction and scarring in the kidney because they also block inflammatory cytokines
bull Use statins for CV disease not to treat proteinuria
(Afzali and Goldsmith 2016)
MEDICINE CAUTION
bull Hold metformin when gfr lt35 mlmin
bull GFR lt50 mlmin should alert to check all doses of meds
bull No bisphosphanates lt35 mlmin
bull No NSAIDScox 2 inhibitors lt60 mlmin
bull Atenolol ndashrenal excretion
bull BACTRIM A lot of AKI
MEDICINE CAUTION
bull Lovenox-use subcut heparinbull Apixibanbull Dabigatranbull Rivaroxibanbull Lithiumbull GABAPENTIN (ckd 4 max 300mg qd ckd 5 max 300mg qod)
STEPS TO CKD PATIENT CARE
1 CKD definition and risks2 Assess GFR albuminuria3 Determine etiology4 Assess for evidence of progression5 Assess for associated complications6 Discuss dialysistransplantation
CKD-CVD-DIABETES LINK CKD IS A DISEASE MULTIPLIER
National kidney foundation 2014
KDIGO 2017
CKD-MINERAL BONE DISORDERS
bull As kidneys fail they
bull Stop activating calcitriol (the active form of Vit D)mdashcausing calcium imbalance
bull Do not remove phosphorus from bloodmdashleading to phosphorus retention
bull The extra phosphorus pulls calcium out of bones causing them to weaken
bull High phosphorus stimulates PTH release
bull These changes (plus others) cause the start of secondary hyperparathyroidism
bull Labs
bull eGFR
bull Calcium
bull Phos
bull Vit D
bull iPTH
(Qunibi amp Henrich 2017)
PREVALENCE OF ABNORMALITIES OF MINERAL METABOLISM PTH IN CKD
bull Progression of disease ndash declining eGFR increasing proteinuria
bull Degree of proteinuria nephrotic syndrome gt 05-10 gd on ACEi or ARB therapy
bull Etiology of CKD not certain
bull Need help with disease management
bull Indications for kidney biopsy
Rosenberg 2016
WHEN TO REFER
STEPS TO CKD PATIENT CARE
1 CKD definition and risks2 Assess GFR albuminuria3 Determine etiology4 Assess for evidence of progression5 Assess for associated complications6 Discuss dialysistransplantation
KIDNEY TRANSPLANTATION
bull Treatment of choice for ESRDbull Improves quality of lifebull Waiting list time varies-3-5 yearsbull 3 year survival rate after transplantation is 83-94bull Increased risk of cancer
STARTING DIALYSIS IN THE ELDERLYhellipOR NOT
bull Among patients gt 75 yrs with stage 5 CKD who chose to NOT start dialysisbull Overall more likely to die over next 1-2 years bull But if they had ischemic heart disease or other significant comorbidity NO
DIFFERENCE in survival
bull Active disease management and supportive care may be appropriate without starting dialysis in the ill elderly
bull Palliative care does not mean ldquono carerdquo
bull Must have end-of-life discussions
(Murtagh et al 2007)
CKD MANAGEMENTbull Diagnose cause and treat underlying conditionbull Stage per guidelinesbull Slow progression of kidney disease (ACE inhibitors)bull Monitor for complicationsmdashvolume overload hyperkalemia metabolic acidosis
hyperphosphatemia anorexia fatigue htn bone diseasebull Labs cmp cbc phos Vit D 25OH iPTH urine microscopy uric acid urine
proteincr ratio-frequency based off heat map Get sono at least oncebull Vaccinate influenza hep B pneumococcalbull Eval ASCVD risk-likely needs statinbull Possible dexa (donrsquot give bisphosphonates if GFRlt35 let specialist manage)bull Refer to nephrology when eGFR is lt30 (sometimes if higher risk-refer earlier)
CASE 1
bull 55 year old man with past medical history of headaches presents to your office for his first time visit to a PCP in over 30 years
bull He has no past history of being admitted to the hospital and he does not take any OTC medsNSAIDsherbal meds He has no history of ETOH abuse smoking or drug use
bull Vitals BP 180100 mmHg pulse 80 R 18
bull Exam No JVD S1S2 regular PMI shifted to the left no gallop no abdominal bruit pulses bilaterally equal and regular no leg edema
bull What would you order
bull EKG cbc cmp ua urine proteincr ratio lipid
LAB RESULTS
bull Labs reveal a creatinine of 22 mgdL eGFR 33 Urine shows no blood or casts Urineprotein ratio shows 1 gm protein24 hrs EKG shows LVH
bull Next step in workupbull Renal ultrasound 1st then SPEP UPEP with immunofixation serum free light chains
bull Additional labs neg Renal ultrasound shows that both kidneys are slightly reduced in size and are mildly echogenic with no mass or hydronephrosis
bull What is your diagnosis
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileMain_complications_of_persistent_high_blood_pressurepngCreative Commons License associated httpcreativecommonsorglicensesby-sa30
bull 3 months Howevermdashwe have evidence of structural abnormalities Could potentially stage at G3b A3 (red on the heat map)
bull Goal blood pressure
bull JNC 8 14090 NKF 13080
bull Additional lab needed for progression monitoring
bull Cbc renal panel phos Vit D iPTH uric acid urine micro (we already have the renal sono and urine proteincr ratio and lipid)
Selective renal angiography (left lower renal artery) after successful percutaneous balloon dilatation of the stenotic lesionFibromuscular dysplasia in an accessory renal artery causing renovascular hypertension
Secondary Hypertension
Images retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileRenal_FMD2jpg and httpcommonswikimediaorgwikiFileRenal_FMDjpgCreative Commons License associated httpcreativecommonsorglicensesby20deeden (both images)
CASE 2bull OS is a 64year old Hispanic female in for DM check She has had DM for 15+ years and is currently
taking metformin 1000mg bid Lisinopril 10mg a day atorvastatin 40mg a day Labs today showed the following
bull Hgba1c 86 cmp eGFR 50 lipid WNL proteincr ratio 650mg These results are similar to her last visit
bull Upon further hx-you find that she had a recent eye exam and has mild nonproliferaive retinopathy She does not have neuropathy or other ss
bull What further workup do you need
bull Renal sonogram urine micro iPTH vit D (25 OH) phos uric acid
bull Dx stage
bull G3a A3
bull What further treatment do you need
bull Improve glycemic control Increase Lisinopril to 20mg with a goal of 40mg Avoid NSAIDs or other nephrotoxic agents make sure meds are renally dosed monitor 3xyear nephro referral
MANAGEMENT OF CKD IN DIABETESeGFR Recommended
All patients
Yearly measurement of creatinine urinary albumin excretion potassium
45-60 Referral to a nephrologist if possibility for nondiabetickidney disease existsConsider dose adjustment of medicationsMonitor eGFR every 6 monthsMonitor electrolytes bicarbonate hemoglobin calcium phosphorus parathyroid hormone at least yearly
Assure vitamin D sufficiencyConsider bone density testingReferral for dietary counselling
American Diabetes Association Standards of Medical Care in Diabetes Microvascular complications and foot care Diabetes Care 2017 40 (Suppl 1) S88-S98
CASE 3
bull 19 year old African American woman presents to your clinic with complaints of fatigue joint pains a new rash on her face oral ulcer
bull On exam BP 15080 P 88 Afebrile 96 O2 sats on RAbull GEN No respiratory distress at restbull HEENT painless oral ulcer flat rash over malar eminences sparing the nasolabial fold pallor +bull Lungs CTAbull CVS S1S2 regularbull Abdomen soft NTbull Ext left elbow joint and bilateral wrist joints are swollen and tender
bull What would you orderbull CBC CMP ua urine microscopy (microalbumin or urine proteincr ratio) ANA esr RF anti-ccp uric acid TSH
CASE 3
bull Working dx fatigue oral ulcer joint pain
bull Basic Labs Na 135 K 55 Bicarb 18 BUN 50 Cr 35 eGFR 22 Ca 90 ANA + titer 1640
bull UA 3+ blood 3+ protein RBC casts +
bull Given these results what is the most likely diagnosis
bull What would you do
SYSTEMIC LUPUS ERYTHEMATOSUS (SLE)
bull SLE multisystemic disease Etiology unknown
bull Production of autoantibodies and immune complexes formation
bull There is renal involvement in the great majority of patients with SLE at some time of the evolution 66-90
SLE ndash LUPUS NEPHRITIS
bull Race SLE is more commonsevere in African americans than Caucasiansbull
bull Gender female-to-male ratio of 91
bull Age Most patients develop lupus nephritis early in their disease course SLE is more common among women in the third decade of life and lupus nephritis occurs in patients aged 20-40 years
bull Kidney Biopsy For staging lupus nephritis (Class 1-5)
CASE 5bull A 80 year old man who has not seen a PCP in many years
presents to your clinic for weakness for the past few months On further questioning he tells you that his bones also have been hurting lately and he has developed leg swelling in the past month or so
bull On exam bull BP 16090 P 88 Afebrilebull GEN Thin built manbull HEENT pallor presentbull Lungs clearbull CVS S1S2 regular no rub or gallopbull Abdomen soft NTbull Ext 2 + edema
CASE 5
bull Differentials
bull CHF MI Cancer arthritis
bull Labs
bull CBC CMP urine microscopy urine proteincr ratio ESR TSH EKG BNP pa and lat CXR
bull LABS Urine dipstick negative for protein or blood
bull Basic chem bull Na 136 (135-145) K 51 (35-55) Chloride 108 (96-106) Bicarb 25
Given this presentation and the labs (low anion gap and elevated calcium anemia kidney failure) what will you think of What will you order next
Serum and urine protein electrophoresis
Intratubular refractile casts with surrounding syncytial giant cell reaction with chronic tubulointerstitial nephritis and fibrosis characteristic of myeloma cast nephropathy
Kidney Biopsy
CASE STUDYbull A 35 year old African American woman was seen in the clinic for
chronic cough and dyspnea on exertion She gave history of vague symptoms of fatigue and weight loss of 20 Ibs over the last six months
bull List some differentialsbull TB sarcoid lupus thyroid problems PEbull What would you orderbull PPD cbc cmp UA TSH ANA pa and lat cxr
bull Her labs were significant for mildly elevated calcium level and a creatinine of 20 mgdL eGFR 37
bull She had 750 mg of proteinuriaday
bull PPD neg ANA neg TSH and other labs WNL
bull Assuming this is present more than 3 monthshelliphellipwhat is her ckd stage
bull G3b A3
bull What do we still need
CT scan of chest
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileAnterior_mediastinal_mass_thymomajpgCreative Commons License associated httpcreativecommonsorglicensesby20deeden
CXR ndash HILAR LYMPHADENOPATHY
WHATS NEEDED NEXT
bull Biopsy of hilar lymphadenopathy or renal biopsy
bull DX sarcoidosis
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileSarcoidosis_signs_and_symptomsjpgThis work is in the public domain in the United States because it is a work of the United States Federal Government under the terms of Title 17 Chapter 1 Section 105 of the US Code
NEWLY DX CKD
bull 1) urinalysis microscopy ultrasound proteincr ratio
bull If obstruction-treat
bull No obstruction
bull Hx critical (consider myeloma if high risk)
bull glomerular bleeding or albumin in urine
bull Yes workup for glomerular causes (ANArf hep B C upep spep ANCA complement C3 C4)
bull No sterile pyruria-consider interstitial nephritis
bull High risk renovascular disease Evaluate renovascular disease
Additional Online Resources for CKD LearningbullNational Kidney Foundation wwwkidneyorgbullUnited States Renal Data Service wwwusrdsorgbullCDCrsquos CKD Surveillance Project
httpnccdcdcgovckdbullNational Kidney Disease Education Program
(NKDEP) httpnkdepnihgov
BIBLIOGRAPHY
bull Afzali B amp Goldsmith D J (2016 June 29) Statins and chronic kidney disease (G C Curhan amp A M Sheridan Eds) Retrieved 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsstatins-and-chronic-kidney-disease
bull American Diabetes Association Standards of Medical Care in Diabetes (2017) Microvascular complications and foot care Diabetes Care 2017 (40) S88-S98
bull American Diabetes Association Standards of Medical Care in Diabetes (2017) Microvascular complications and foot care Diabetes Care 40 (suppl 1) S88-S98
bull Berns J S (2017 Mar 22) Treatment of anemia in nondialysis chronic kidney disease (T A Golper amp A M Sheridan Eds) Retrieved from UpToDate httpswww-uptodate-comproxywichitaeducontentstreatment-of-anemia-in-nondialysis-chronic-kidney-disease
bull Chan M Dall A T Fletcher K E Lu N amp Trivedi H (2007) Outcomes in patients with chronic kidney disease referred late to nephrologists a meta-analysis American Journal of Medicine 120(12) 1063-1070
bull Coresh J Selvin E amp Stevens L A (2007) Prevalence of chronic kidny disease in the United States JAMA 298(17) doi101001jama298172038
bull de Brito-Ashurst I Varagunam M Raftery M amp Yagoob M (2009) Bicarbonate supplementation slows progression of CKD and improves nutritional status Journal of American Society of Nephrology (20) 2075-2084
BIBLIOGRAPHY
bull Duncan L Heathcoat J Djurdjev O amp Levin A (2001) Screening for renal disease using serum creatinine who are we missing Nephrology Dialysis and Transplant 16(5) 1042-1046
bull Dunkler D Gao P Lee S F Heinz G Clase C M Tobe S Oberbauer R (2015 August 7) Risk prediction for early CKD in type 2 diabetes Retrieved from Clinical Journal of the American Society of Nephrology httpcjasnasnjournalsorgcontent1081371fullsid=61422554-a5f1-41ac-b696-dcd3b12bd268
bull Fatehi P amp Chi-yuan H (September 15 2016) Diagnostic approach to the patient with newly identified chronic kidney disease (G C Curhan amp A M Sheridan Eds) Retrieved May 7 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsdiagnostic-approach-to-the-patient-with-newly-identified-chronic-kidney-disease
bull Fink J e (2009) Chronic Kidney Disease as an Under-Recognized Threat to Patient Safety American journal of kidney diseases the official journal of the National Kidney Foundation 53(4) 681-688
bull Gaffo A L amp Saag K G (2008 Nov) Management of hyperuricemia and gout in CKD doihttpdxdoiorg101053jajkd200807035
bull Hebert L A amp Parikh S V (2014 June 18) Differential diagnosis and evaluation of glomerular disease (R J Glassock amp A Q Lam Eds) Retrieved May 7 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsdifferential-diagnosis-and-evaluation-of-glomerular-disease
bull Inker L Perrone R D Sterns R H amp Forman J P (2017 March 7) Assessment of kidney function Retrieved from UpToDate httpswww-uptodate-comproxywichitaeducontentsassessment-of-kidney-functionsource=search_resultampsearch=creatinineampselectedTitle=1~150
BIBLIOGRAPHY
bull James P A Ortiz E amp Et Al (2014) Evidence based guideline for the management of high blood pressure in adults (JNC) JAMA 311(5) 507-520
bull Kidney Disease Improving Global Outcomes (KDIGO) CKD Work Group (2013 January) KDIGO 2012 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease Retrieved from Kidney International Supplement httpwwwkidney-internationalorg
bull Kunz R Friedrich C Wolbers M amp Mann J F (2008) Meta-analysis effect of monotherapy and combination therapy with inhibitors of the renin angiotensin system on proteinuria in renal disease Annals of Internal Medicine 148(1) 30-48
bull Levey A Stevens L A Schmid C H Castro A F Feldman H I Kusek J W Coresh J (2009) A new equation to estimate glomerular filtration rate Annals of Internal Medicine 150(9) 604-612
bull Levin A Bakris G L Molitch M Smulders M M Williams L A amp Andress D L (2007 Jan) Prevalence of abnormal serum vitamin D PTH calcium and phosphorus in patients with chronic kidney disease results of the study to evaluate early kidney disease Kidney International 71(1) 31-38 Retrieved from PubMED
bull Mahajan A Simoni J Sheather S Broglio K Rajab M amp Wesson D (2010) Daily oral sodium bicarbonate preserves glomerular filtration rate by slowing its decline in early hypertensive nephropathy Kidney International (78_ 303-309
bull Mann J Schmieder R E amp McQueen M (2008) Renal outcomes with telmisartan ramipril or both in people at high vascular risk (the ONTARGET study) a multicentre randomised doubleblind ocntrolled trial Lancet 372(9638) 547-533
BIBLIOGRAPHY
bull Matovinović M S (2009) Pathophysiology and classification of kidney disease Retrieved from The Journal of the International Federation of Clinical Chemistry and Laboratory Medicine httpwwwifccorgifccfilesdocs20010902pdf
bull Moe S Drueke T Lameire N amp Eknoyan G (2007 Jan) Chronic kidney disease-mineral-bone disorder a new paradigmdoi101053jackd200610005
bull Murtagh F E Marsh J E Donohoe P Ekbal N J Sheerin N S amp Harris F E (2007 July) Dialysis or not A comparative survival study of patients over 75 years with chronic kidney disease stage 5 Retrieved from Nephrology Dialysis and Transplant 22(7) httpswwwncbinlmnihgovpubmed17412702
bull National Kidney Foundation (2002) KDOQI clinical practice guidelines for chronic kidney disease evaluation classification andstratification American Journal of Kidney Disease S1-S266
bull National Kidney Foundation (2014 November 5) Fact Sheets Retrieved from httpwwwkidneyorgnewsnewsroomfactsheetsFastFacts
bull Pal S (2012 June 2) Trends in chronic kidney disease Retrieved from US Pharmacist (37)6 httpswwwuspharmacistcomarticletrends-in-chronic-kidney-disease
bull Qunibi W amp Henrich W L (2017 Jan 19) Overview of chronic kidney disease-mineral and bone disorder (J Berns amp A M Sheridan Eds) Retrieved from UpToDate httpswww-uptodate-comoverview-of-chronic-kidney-disease-mineral-and-bone-disorder-ckd-mbd
bull Rosenberg M (2016 Feb 24) Overview of the management of chronic kidney disease in adults (G C Curhan amp A M Sheridan Eds) Retrieved from UpToDate UpToDate httpswww-uptodate-comproxywichitaeducontentsoverview-of-the-management-of-chronic-kidney-disease-in-adults
BIBLIOGRAPHY
bull Szczech L Stewart R C Hsu-Lin S DeLosky R J Astor B C Fox C H Vassalotti J A (2014) Primary care detection of chronic kidney disease in adults with type 2 diabetes The ADD-CKD Study (Awareness Detection and Drug Therapy in type 2 diabetes and chronic kidney disease PLOS doihttpsdoiorg101371journalpone0110535
bull USRDS (2016) Annual data report 2016 Epidemiology of kidney disease in the United States Retrieved from United States Renal Data System httpswwwusrdsorgadraspx
bull Vasudev B amp Vasudev M (2012) A model curriculum for residents rotating in nephrology MedEDPORTAL doihttpdoiorg1015766mep_2374-82658288
bull Wei L MacDonald T M Jennings C Sheng X amp Flynn R W (2013) Estimated GFR reporting is associated with decreased nonsteroidal anti-inflammatory drug prescribing and increased renal function Kidney International (84)1 174-178
chronic kidney disease in primary care
CKD as a Public Health Issue
Slide Number 3
Costs of CKD in 2013 dollarsUSRDS report
Steps to CKD Patient Care
Renal anatomy and physiology
Definition of Chronic Kidney Disease
CKD Risk Factors
Gaps in CKD Diagnosis
Slide Number 10
Steps to CKD Patient Care
creatinine
Glomerular filtration rate
Slide Number 14
Slide Number 15
Use These Equations Cautiously if at all in hellip
lab albumin creatinine ratio
The New CKD Categories
Steps to CKD Patient Care
Slide Number 20
Kidney Involvement in Systemic Diseases
Slide Number 22
Slide Number 23
DysmorphicRenal Hematuria
Slide Number 25
If you have albuminuria or hematuria-order the following labs
DIABETIC NEPHROPATHY 1 CAUSE OF CKDbull Clinical syndromebull Albuminuria gt30 mg 24 hrsbull Proteinuria gt500 mg24 hrsbull Hypertension developsbull Progressive increase in proteinuriabull Progressive decline in glomerular filtration rate
bull Chronic kidney disease should be attributed to diabetic nephropathies in most patients with diabetes if albuminuria and diabetic retinopathy are both present other causes of CKD should be entertained if diabetic retinopathy is absent (KDIGO 2007)
DIABETIC NEPHROPATHY MORTALITY
bull After 40 yrs of DM
bull 10 alive if proteinuria is present
bull 70 alive if proteinuria is absent
bull Heart Disease is 15 times higher risk in those with proteinuria
bull Proteinuria = death in this population
Dunkler et al 2015
GOALS OF CARE IN CKD GLUCOSE CONTROL
bull Target HbA1c ~70 (lt695 greatest chance of reducing albuminuria)bull Can be extended above 70 with comorbidities or limited life expectancy and
risk of hypoglycemiabull Risk of hypoglycemia increases as kidney function becomes impairedbull Declining kidney function may necessitate changes to diabetes medications and
bull Just having HTN can cause proteinuriabull Usually 1-2 gms of protein a daybull Treat them like a diabetic with ACEI or ARBS and tight blood
pressure controlbull JNC-8 goal lt14090 for ptrsquos with CKDbull National kidney foundation lt14090 if ckd and no proteinuria
lt13080 if proteinuria present
(James Ortiz amp Et Al 2014)
TREATING HYPERTENSIONPROTEINURIA ACEI ORARBbull Riskbenefit should be carefully assessed in the elderly and medically fragilebull Check labs after initiation
bull If less than 30 SCr increase continue and monitorbull If more than 30 SCr increase stop ACEi and evaluate for renal artery stenosis
bull Continue until contraindication arises no absolute eGFR cutoffbull Better proteinuria suppression with low Na diet and diureticsbull Avoid volume depletionbull Avoid ACEi and ARB in combination12
bull Risk of adverse events (impaired kidney function hyperkalemia)
(Kunz Friedrich Wolbers amp Mann 2008)(Mann Schmieder amp McQueen 2008)
bull In adults gt50 yrs statin when eGFR ge 60 mlmin173m2 statin or statinezetimibe combination when eGFR lt 60 mlmin173m2
bull In adults lt 50 yrs statin if history of known CAD MI DM strokebull Aspirin is indicated for secondary but not primary prevention
Kidney Disease Improving Global Outcomes (KDIGO) CKD Work Group Kidney Int Suppls 201331-150
STATINS-RENOPROTECTIVECONTROVERSY
bull HMG-CoA reductase inhibitors (statins) in high doses can cause proteinuria
bull Possibly associated with less inflammation endothelial dysfunction and scarring in the kidney because they also block inflammatory cytokines
bull Use statins for CV disease not to treat proteinuria
(Afzali and Goldsmith 2016)
MEDICINE CAUTION
bull Hold metformin when gfr lt35 mlmin
bull GFR lt50 mlmin should alert to check all doses of meds
bull No bisphosphanates lt35 mlmin
bull No NSAIDScox 2 inhibitors lt60 mlmin
bull Atenolol ndashrenal excretion
bull BACTRIM A lot of AKI
MEDICINE CAUTION
bull Lovenox-use subcut heparinbull Apixibanbull Dabigatranbull Rivaroxibanbull Lithiumbull GABAPENTIN (ckd 4 max 300mg qd ckd 5 max 300mg qod)
STEPS TO CKD PATIENT CARE
1 CKD definition and risks2 Assess GFR albuminuria3 Determine etiology4 Assess for evidence of progression5 Assess for associated complications6 Discuss dialysistransplantation
CKD-CVD-DIABETES LINK CKD IS A DISEASE MULTIPLIER
National kidney foundation 2014
KDIGO 2017
CKD-MINERAL BONE DISORDERS
bull As kidneys fail they
bull Stop activating calcitriol (the active form of Vit D)mdashcausing calcium imbalance
bull Do not remove phosphorus from bloodmdashleading to phosphorus retention
bull The extra phosphorus pulls calcium out of bones causing them to weaken
bull High phosphorus stimulates PTH release
bull These changes (plus others) cause the start of secondary hyperparathyroidism
bull Labs
bull eGFR
bull Calcium
bull Phos
bull Vit D
bull iPTH
(Qunibi amp Henrich 2017)
PREVALENCE OF ABNORMALITIES OF MINERAL METABOLISM PTH IN CKD
bull Progression of disease ndash declining eGFR increasing proteinuria
bull Degree of proteinuria nephrotic syndrome gt 05-10 gd on ACEi or ARB therapy
bull Etiology of CKD not certain
bull Need help with disease management
bull Indications for kidney biopsy
Rosenberg 2016
WHEN TO REFER
STEPS TO CKD PATIENT CARE
1 CKD definition and risks2 Assess GFR albuminuria3 Determine etiology4 Assess for evidence of progression5 Assess for associated complications6 Discuss dialysistransplantation
KIDNEY TRANSPLANTATION
bull Treatment of choice for ESRDbull Improves quality of lifebull Waiting list time varies-3-5 yearsbull 3 year survival rate after transplantation is 83-94bull Increased risk of cancer
STARTING DIALYSIS IN THE ELDERLYhellipOR NOT
bull Among patients gt 75 yrs with stage 5 CKD who chose to NOT start dialysisbull Overall more likely to die over next 1-2 years bull But if they had ischemic heart disease or other significant comorbidity NO
DIFFERENCE in survival
bull Active disease management and supportive care may be appropriate without starting dialysis in the ill elderly
bull Palliative care does not mean ldquono carerdquo
bull Must have end-of-life discussions
(Murtagh et al 2007)
CKD MANAGEMENTbull Diagnose cause and treat underlying conditionbull Stage per guidelinesbull Slow progression of kidney disease (ACE inhibitors)bull Monitor for complicationsmdashvolume overload hyperkalemia metabolic acidosis
hyperphosphatemia anorexia fatigue htn bone diseasebull Labs cmp cbc phos Vit D 25OH iPTH urine microscopy uric acid urine
proteincr ratio-frequency based off heat map Get sono at least oncebull Vaccinate influenza hep B pneumococcalbull Eval ASCVD risk-likely needs statinbull Possible dexa (donrsquot give bisphosphonates if GFRlt35 let specialist manage)bull Refer to nephrology when eGFR is lt30 (sometimes if higher risk-refer earlier)
CASE 1
bull 55 year old man with past medical history of headaches presents to your office for his first time visit to a PCP in over 30 years
bull He has no past history of being admitted to the hospital and he does not take any OTC medsNSAIDsherbal meds He has no history of ETOH abuse smoking or drug use
bull Vitals BP 180100 mmHg pulse 80 R 18
bull Exam No JVD S1S2 regular PMI shifted to the left no gallop no abdominal bruit pulses bilaterally equal and regular no leg edema
bull What would you order
bull EKG cbc cmp ua urine proteincr ratio lipid
LAB RESULTS
bull Labs reveal a creatinine of 22 mgdL eGFR 33 Urine shows no blood or casts Urineprotein ratio shows 1 gm protein24 hrs EKG shows LVH
bull Next step in workupbull Renal ultrasound 1st then SPEP UPEP with immunofixation serum free light chains
bull Additional labs neg Renal ultrasound shows that both kidneys are slightly reduced in size and are mildly echogenic with no mass or hydronephrosis
bull What is your diagnosis
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileMain_complications_of_persistent_high_blood_pressurepngCreative Commons License associated httpcreativecommonsorglicensesby-sa30
bull 3 months Howevermdashwe have evidence of structural abnormalities Could potentially stage at G3b A3 (red on the heat map)
bull Goal blood pressure
bull JNC 8 14090 NKF 13080
bull Additional lab needed for progression monitoring
bull Cbc renal panel phos Vit D iPTH uric acid urine micro (we already have the renal sono and urine proteincr ratio and lipid)
Selective renal angiography (left lower renal artery) after successful percutaneous balloon dilatation of the stenotic lesionFibromuscular dysplasia in an accessory renal artery causing renovascular hypertension
Secondary Hypertension
Images retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileRenal_FMD2jpg and httpcommonswikimediaorgwikiFileRenal_FMDjpgCreative Commons License associated httpcreativecommonsorglicensesby20deeden (both images)
CASE 2bull OS is a 64year old Hispanic female in for DM check She has had DM for 15+ years and is currently
taking metformin 1000mg bid Lisinopril 10mg a day atorvastatin 40mg a day Labs today showed the following
bull Hgba1c 86 cmp eGFR 50 lipid WNL proteincr ratio 650mg These results are similar to her last visit
bull Upon further hx-you find that she had a recent eye exam and has mild nonproliferaive retinopathy She does not have neuropathy or other ss
bull What further workup do you need
bull Renal sonogram urine micro iPTH vit D (25 OH) phos uric acid
bull Dx stage
bull G3a A3
bull What further treatment do you need
bull Improve glycemic control Increase Lisinopril to 20mg with a goal of 40mg Avoid NSAIDs or other nephrotoxic agents make sure meds are renally dosed monitor 3xyear nephro referral
MANAGEMENT OF CKD IN DIABETESeGFR Recommended
All patients
Yearly measurement of creatinine urinary albumin excretion potassium
45-60 Referral to a nephrologist if possibility for nondiabetickidney disease existsConsider dose adjustment of medicationsMonitor eGFR every 6 monthsMonitor electrolytes bicarbonate hemoglobin calcium phosphorus parathyroid hormone at least yearly
Assure vitamin D sufficiencyConsider bone density testingReferral for dietary counselling
American Diabetes Association Standards of Medical Care in Diabetes Microvascular complications and foot care Diabetes Care 2017 40 (Suppl 1) S88-S98
CASE 3
bull 19 year old African American woman presents to your clinic with complaints of fatigue joint pains a new rash on her face oral ulcer
bull On exam BP 15080 P 88 Afebrile 96 O2 sats on RAbull GEN No respiratory distress at restbull HEENT painless oral ulcer flat rash over malar eminences sparing the nasolabial fold pallor +bull Lungs CTAbull CVS S1S2 regularbull Abdomen soft NTbull Ext left elbow joint and bilateral wrist joints are swollen and tender
bull What would you orderbull CBC CMP ua urine microscopy (microalbumin or urine proteincr ratio) ANA esr RF anti-ccp uric acid TSH
CASE 3
bull Working dx fatigue oral ulcer joint pain
bull Basic Labs Na 135 K 55 Bicarb 18 BUN 50 Cr 35 eGFR 22 Ca 90 ANA + titer 1640
bull UA 3+ blood 3+ protein RBC casts +
bull Given these results what is the most likely diagnosis
bull What would you do
SYSTEMIC LUPUS ERYTHEMATOSUS (SLE)
bull SLE multisystemic disease Etiology unknown
bull Production of autoantibodies and immune complexes formation
bull There is renal involvement in the great majority of patients with SLE at some time of the evolution 66-90
SLE ndash LUPUS NEPHRITIS
bull Race SLE is more commonsevere in African americans than Caucasiansbull
bull Gender female-to-male ratio of 91
bull Age Most patients develop lupus nephritis early in their disease course SLE is more common among women in the third decade of life and lupus nephritis occurs in patients aged 20-40 years
bull Kidney Biopsy For staging lupus nephritis (Class 1-5)
CASE 5bull A 80 year old man who has not seen a PCP in many years
presents to your clinic for weakness for the past few months On further questioning he tells you that his bones also have been hurting lately and he has developed leg swelling in the past month or so
bull On exam bull BP 16090 P 88 Afebrilebull GEN Thin built manbull HEENT pallor presentbull Lungs clearbull CVS S1S2 regular no rub or gallopbull Abdomen soft NTbull Ext 2 + edema
CASE 5
bull Differentials
bull CHF MI Cancer arthritis
bull Labs
bull CBC CMP urine microscopy urine proteincr ratio ESR TSH EKG BNP pa and lat CXR
bull LABS Urine dipstick negative for protein or blood
bull Basic chem bull Na 136 (135-145) K 51 (35-55) Chloride 108 (96-106) Bicarb 25
Given this presentation and the labs (low anion gap and elevated calcium anemia kidney failure) what will you think of What will you order next
Serum and urine protein electrophoresis
Intratubular refractile casts with surrounding syncytial giant cell reaction with chronic tubulointerstitial nephritis and fibrosis characteristic of myeloma cast nephropathy
Kidney Biopsy
CASE STUDYbull A 35 year old African American woman was seen in the clinic for
chronic cough and dyspnea on exertion She gave history of vague symptoms of fatigue and weight loss of 20 Ibs over the last six months
bull List some differentialsbull TB sarcoid lupus thyroid problems PEbull What would you orderbull PPD cbc cmp UA TSH ANA pa and lat cxr
bull Her labs were significant for mildly elevated calcium level and a creatinine of 20 mgdL eGFR 37
bull She had 750 mg of proteinuriaday
bull PPD neg ANA neg TSH and other labs WNL
bull Assuming this is present more than 3 monthshelliphellipwhat is her ckd stage
bull G3b A3
bull What do we still need
CT scan of chest
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileAnterior_mediastinal_mass_thymomajpgCreative Commons License associated httpcreativecommonsorglicensesby20deeden
CXR ndash HILAR LYMPHADENOPATHY
WHATS NEEDED NEXT
bull Biopsy of hilar lymphadenopathy or renal biopsy
bull DX sarcoidosis
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileSarcoidosis_signs_and_symptomsjpgThis work is in the public domain in the United States because it is a work of the United States Federal Government under the terms of Title 17 Chapter 1 Section 105 of the US Code
NEWLY DX CKD
bull 1) urinalysis microscopy ultrasound proteincr ratio
bull If obstruction-treat
bull No obstruction
bull Hx critical (consider myeloma if high risk)
bull glomerular bleeding or albumin in urine
bull Yes workup for glomerular causes (ANArf hep B C upep spep ANCA complement C3 C4)
bull No sterile pyruria-consider interstitial nephritis
bull High risk renovascular disease Evaluate renovascular disease
Additional Online Resources for CKD LearningbullNational Kidney Foundation wwwkidneyorgbullUnited States Renal Data Service wwwusrdsorgbullCDCrsquos CKD Surveillance Project
httpnccdcdcgovckdbullNational Kidney Disease Education Program
(NKDEP) httpnkdepnihgov
BIBLIOGRAPHY
bull Afzali B amp Goldsmith D J (2016 June 29) Statins and chronic kidney disease (G C Curhan amp A M Sheridan Eds) Retrieved 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsstatins-and-chronic-kidney-disease
bull American Diabetes Association Standards of Medical Care in Diabetes (2017) Microvascular complications and foot care Diabetes Care 2017 (40) S88-S98
bull American Diabetes Association Standards of Medical Care in Diabetes (2017) Microvascular complications and foot care Diabetes Care 40 (suppl 1) S88-S98
bull Berns J S (2017 Mar 22) Treatment of anemia in nondialysis chronic kidney disease (T A Golper amp A M Sheridan Eds) Retrieved from UpToDate httpswww-uptodate-comproxywichitaeducontentstreatment-of-anemia-in-nondialysis-chronic-kidney-disease
bull Chan M Dall A T Fletcher K E Lu N amp Trivedi H (2007) Outcomes in patients with chronic kidney disease referred late to nephrologists a meta-analysis American Journal of Medicine 120(12) 1063-1070
bull Coresh J Selvin E amp Stevens L A (2007) Prevalence of chronic kidny disease in the United States JAMA 298(17) doi101001jama298172038
bull de Brito-Ashurst I Varagunam M Raftery M amp Yagoob M (2009) Bicarbonate supplementation slows progression of CKD and improves nutritional status Journal of American Society of Nephrology (20) 2075-2084
BIBLIOGRAPHY
bull Duncan L Heathcoat J Djurdjev O amp Levin A (2001) Screening for renal disease using serum creatinine who are we missing Nephrology Dialysis and Transplant 16(5) 1042-1046
bull Dunkler D Gao P Lee S F Heinz G Clase C M Tobe S Oberbauer R (2015 August 7) Risk prediction for early CKD in type 2 diabetes Retrieved from Clinical Journal of the American Society of Nephrology httpcjasnasnjournalsorgcontent1081371fullsid=61422554-a5f1-41ac-b696-dcd3b12bd268
bull Fatehi P amp Chi-yuan H (September 15 2016) Diagnostic approach to the patient with newly identified chronic kidney disease (G C Curhan amp A M Sheridan Eds) Retrieved May 7 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsdiagnostic-approach-to-the-patient-with-newly-identified-chronic-kidney-disease
bull Fink J e (2009) Chronic Kidney Disease as an Under-Recognized Threat to Patient Safety American journal of kidney diseases the official journal of the National Kidney Foundation 53(4) 681-688
bull Gaffo A L amp Saag K G (2008 Nov) Management of hyperuricemia and gout in CKD doihttpdxdoiorg101053jajkd200807035
bull Hebert L A amp Parikh S V (2014 June 18) Differential diagnosis and evaluation of glomerular disease (R J Glassock amp A Q Lam Eds) Retrieved May 7 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsdifferential-diagnosis-and-evaluation-of-glomerular-disease
bull Inker L Perrone R D Sterns R H amp Forman J P (2017 March 7) Assessment of kidney function Retrieved from UpToDate httpswww-uptodate-comproxywichitaeducontentsassessment-of-kidney-functionsource=search_resultampsearch=creatinineampselectedTitle=1~150
BIBLIOGRAPHY
bull James P A Ortiz E amp Et Al (2014) Evidence based guideline for the management of high blood pressure in adults (JNC) JAMA 311(5) 507-520
bull Kidney Disease Improving Global Outcomes (KDIGO) CKD Work Group (2013 January) KDIGO 2012 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease Retrieved from Kidney International Supplement httpwwwkidney-internationalorg
bull Kunz R Friedrich C Wolbers M amp Mann J F (2008) Meta-analysis effect of monotherapy and combination therapy with inhibitors of the renin angiotensin system on proteinuria in renal disease Annals of Internal Medicine 148(1) 30-48
bull Levey A Stevens L A Schmid C H Castro A F Feldman H I Kusek J W Coresh J (2009) A new equation to estimate glomerular filtration rate Annals of Internal Medicine 150(9) 604-612
bull Levin A Bakris G L Molitch M Smulders M M Williams L A amp Andress D L (2007 Jan) Prevalence of abnormal serum vitamin D PTH calcium and phosphorus in patients with chronic kidney disease results of the study to evaluate early kidney disease Kidney International 71(1) 31-38 Retrieved from PubMED
bull Mahajan A Simoni J Sheather S Broglio K Rajab M amp Wesson D (2010) Daily oral sodium bicarbonate preserves glomerular filtration rate by slowing its decline in early hypertensive nephropathy Kidney International (78_ 303-309
bull Mann J Schmieder R E amp McQueen M (2008) Renal outcomes with telmisartan ramipril or both in people at high vascular risk (the ONTARGET study) a multicentre randomised doubleblind ocntrolled trial Lancet 372(9638) 547-533
BIBLIOGRAPHY
bull Matovinović M S (2009) Pathophysiology and classification of kidney disease Retrieved from The Journal of the International Federation of Clinical Chemistry and Laboratory Medicine httpwwwifccorgifccfilesdocs20010902pdf
bull Moe S Drueke T Lameire N amp Eknoyan G (2007 Jan) Chronic kidney disease-mineral-bone disorder a new paradigmdoi101053jackd200610005
bull Murtagh F E Marsh J E Donohoe P Ekbal N J Sheerin N S amp Harris F E (2007 July) Dialysis or not A comparative survival study of patients over 75 years with chronic kidney disease stage 5 Retrieved from Nephrology Dialysis and Transplant 22(7) httpswwwncbinlmnihgovpubmed17412702
bull National Kidney Foundation (2002) KDOQI clinical practice guidelines for chronic kidney disease evaluation classification andstratification American Journal of Kidney Disease S1-S266
bull National Kidney Foundation (2014 November 5) Fact Sheets Retrieved from httpwwwkidneyorgnewsnewsroomfactsheetsFastFacts
bull Pal S (2012 June 2) Trends in chronic kidney disease Retrieved from US Pharmacist (37)6 httpswwwuspharmacistcomarticletrends-in-chronic-kidney-disease
bull Qunibi W amp Henrich W L (2017 Jan 19) Overview of chronic kidney disease-mineral and bone disorder (J Berns amp A M Sheridan Eds) Retrieved from UpToDate httpswww-uptodate-comoverview-of-chronic-kidney-disease-mineral-and-bone-disorder-ckd-mbd
bull Rosenberg M (2016 Feb 24) Overview of the management of chronic kidney disease in adults (G C Curhan amp A M Sheridan Eds) Retrieved from UpToDate UpToDate httpswww-uptodate-comproxywichitaeducontentsoverview-of-the-management-of-chronic-kidney-disease-in-adults
BIBLIOGRAPHY
bull Szczech L Stewart R C Hsu-Lin S DeLosky R J Astor B C Fox C H Vassalotti J A (2014) Primary care detection of chronic kidney disease in adults with type 2 diabetes The ADD-CKD Study (Awareness Detection and Drug Therapy in type 2 diabetes and chronic kidney disease PLOS doihttpsdoiorg101371journalpone0110535
bull USRDS (2016) Annual data report 2016 Epidemiology of kidney disease in the United States Retrieved from United States Renal Data System httpswwwusrdsorgadraspx
bull Vasudev B amp Vasudev M (2012) A model curriculum for residents rotating in nephrology MedEDPORTAL doihttpdoiorg1015766mep_2374-82658288
bull Wei L MacDonald T M Jennings C Sheng X amp Flynn R W (2013) Estimated GFR reporting is associated with decreased nonsteroidal anti-inflammatory drug prescribing and increased renal function Kidney International (84)1 174-178
chronic kidney disease in primary care
CKD as a Public Health Issue
Slide Number 3
Costs of CKD in 2013 dollarsUSRDS report
Steps to CKD Patient Care
Renal anatomy and physiology
Definition of Chronic Kidney Disease
CKD Risk Factors
Gaps in CKD Diagnosis
Slide Number 10
Steps to CKD Patient Care
creatinine
Glomerular filtration rate
Slide Number 14
Slide Number 15
Use These Equations Cautiously if at all in hellip
lab albumin creatinine ratio
The New CKD Categories
Steps to CKD Patient Care
Slide Number 20
Kidney Involvement in Systemic Diseases
Slide Number 22
Slide Number 23
DysmorphicRenal Hematuria
Slide Number 25
If you have albuminuria or hematuria-order the following labs
DIABETIC NEPHROPATHY 1 CAUSE OF CKDbull Clinical syndromebull Albuminuria gt30 mg 24 hrsbull Proteinuria gt500 mg24 hrsbull Hypertension developsbull Progressive increase in proteinuriabull Progressive decline in glomerular filtration rate
bull Chronic kidney disease should be attributed to diabetic nephropathies in most patients with diabetes if albuminuria and diabetic retinopathy are both present other causes of CKD should be entertained if diabetic retinopathy is absent (KDIGO 2007)
DIABETIC NEPHROPATHY MORTALITY
bull After 40 yrs of DM
bull 10 alive if proteinuria is present
bull 70 alive if proteinuria is absent
bull Heart Disease is 15 times higher risk in those with proteinuria
bull Proteinuria = death in this population
Dunkler et al 2015
GOALS OF CARE IN CKD GLUCOSE CONTROL
bull Target HbA1c ~70 (lt695 greatest chance of reducing albuminuria)bull Can be extended above 70 with comorbidities or limited life expectancy and
risk of hypoglycemiabull Risk of hypoglycemia increases as kidney function becomes impairedbull Declining kidney function may necessitate changes to diabetes medications and
bull Just having HTN can cause proteinuriabull Usually 1-2 gms of protein a daybull Treat them like a diabetic with ACEI or ARBS and tight blood
pressure controlbull JNC-8 goal lt14090 for ptrsquos with CKDbull National kidney foundation lt14090 if ckd and no proteinuria
lt13080 if proteinuria present
(James Ortiz amp Et Al 2014)
TREATING HYPERTENSIONPROTEINURIA ACEI ORARBbull Riskbenefit should be carefully assessed in the elderly and medically fragilebull Check labs after initiation
bull If less than 30 SCr increase continue and monitorbull If more than 30 SCr increase stop ACEi and evaluate for renal artery stenosis
bull Continue until contraindication arises no absolute eGFR cutoffbull Better proteinuria suppression with low Na diet and diureticsbull Avoid volume depletionbull Avoid ACEi and ARB in combination12
bull Risk of adverse events (impaired kidney function hyperkalemia)
(Kunz Friedrich Wolbers amp Mann 2008)(Mann Schmieder amp McQueen 2008)
bull In adults gt50 yrs statin when eGFR ge 60 mlmin173m2 statin or statinezetimibe combination when eGFR lt 60 mlmin173m2
bull In adults lt 50 yrs statin if history of known CAD MI DM strokebull Aspirin is indicated for secondary but not primary prevention
Kidney Disease Improving Global Outcomes (KDIGO) CKD Work Group Kidney Int Suppls 201331-150
STATINS-RENOPROTECTIVECONTROVERSY
bull HMG-CoA reductase inhibitors (statins) in high doses can cause proteinuria
bull Possibly associated with less inflammation endothelial dysfunction and scarring in the kidney because they also block inflammatory cytokines
bull Use statins for CV disease not to treat proteinuria
(Afzali and Goldsmith 2016)
MEDICINE CAUTION
bull Hold metformin when gfr lt35 mlmin
bull GFR lt50 mlmin should alert to check all doses of meds
bull No bisphosphanates lt35 mlmin
bull No NSAIDScox 2 inhibitors lt60 mlmin
bull Atenolol ndashrenal excretion
bull BACTRIM A lot of AKI
MEDICINE CAUTION
bull Lovenox-use subcut heparinbull Apixibanbull Dabigatranbull Rivaroxibanbull Lithiumbull GABAPENTIN (ckd 4 max 300mg qd ckd 5 max 300mg qod)
STEPS TO CKD PATIENT CARE
1 CKD definition and risks2 Assess GFR albuminuria3 Determine etiology4 Assess for evidence of progression5 Assess for associated complications6 Discuss dialysistransplantation
CKD-CVD-DIABETES LINK CKD IS A DISEASE MULTIPLIER
National kidney foundation 2014
KDIGO 2017
CKD-MINERAL BONE DISORDERS
bull As kidneys fail they
bull Stop activating calcitriol (the active form of Vit D)mdashcausing calcium imbalance
bull Do not remove phosphorus from bloodmdashleading to phosphorus retention
bull The extra phosphorus pulls calcium out of bones causing them to weaken
bull High phosphorus stimulates PTH release
bull These changes (plus others) cause the start of secondary hyperparathyroidism
bull Labs
bull eGFR
bull Calcium
bull Phos
bull Vit D
bull iPTH
(Qunibi amp Henrich 2017)
PREVALENCE OF ABNORMALITIES OF MINERAL METABOLISM PTH IN CKD
bull Progression of disease ndash declining eGFR increasing proteinuria
bull Degree of proteinuria nephrotic syndrome gt 05-10 gd on ACEi or ARB therapy
bull Etiology of CKD not certain
bull Need help with disease management
bull Indications for kidney biopsy
Rosenberg 2016
WHEN TO REFER
STEPS TO CKD PATIENT CARE
1 CKD definition and risks2 Assess GFR albuminuria3 Determine etiology4 Assess for evidence of progression5 Assess for associated complications6 Discuss dialysistransplantation
KIDNEY TRANSPLANTATION
bull Treatment of choice for ESRDbull Improves quality of lifebull Waiting list time varies-3-5 yearsbull 3 year survival rate after transplantation is 83-94bull Increased risk of cancer
STARTING DIALYSIS IN THE ELDERLYhellipOR NOT
bull Among patients gt 75 yrs with stage 5 CKD who chose to NOT start dialysisbull Overall more likely to die over next 1-2 years bull But if they had ischemic heart disease or other significant comorbidity NO
DIFFERENCE in survival
bull Active disease management and supportive care may be appropriate without starting dialysis in the ill elderly
bull Palliative care does not mean ldquono carerdquo
bull Must have end-of-life discussions
(Murtagh et al 2007)
CKD MANAGEMENTbull Diagnose cause and treat underlying conditionbull Stage per guidelinesbull Slow progression of kidney disease (ACE inhibitors)bull Monitor for complicationsmdashvolume overload hyperkalemia metabolic acidosis
hyperphosphatemia anorexia fatigue htn bone diseasebull Labs cmp cbc phos Vit D 25OH iPTH urine microscopy uric acid urine
proteincr ratio-frequency based off heat map Get sono at least oncebull Vaccinate influenza hep B pneumococcalbull Eval ASCVD risk-likely needs statinbull Possible dexa (donrsquot give bisphosphonates if GFRlt35 let specialist manage)bull Refer to nephrology when eGFR is lt30 (sometimes if higher risk-refer earlier)
CASE 1
bull 55 year old man with past medical history of headaches presents to your office for his first time visit to a PCP in over 30 years
bull He has no past history of being admitted to the hospital and he does not take any OTC medsNSAIDsherbal meds He has no history of ETOH abuse smoking or drug use
bull Vitals BP 180100 mmHg pulse 80 R 18
bull Exam No JVD S1S2 regular PMI shifted to the left no gallop no abdominal bruit pulses bilaterally equal and regular no leg edema
bull What would you order
bull EKG cbc cmp ua urine proteincr ratio lipid
LAB RESULTS
bull Labs reveal a creatinine of 22 mgdL eGFR 33 Urine shows no blood or casts Urineprotein ratio shows 1 gm protein24 hrs EKG shows LVH
bull Next step in workupbull Renal ultrasound 1st then SPEP UPEP with immunofixation serum free light chains
bull Additional labs neg Renal ultrasound shows that both kidneys are slightly reduced in size and are mildly echogenic with no mass or hydronephrosis
bull What is your diagnosis
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileMain_complications_of_persistent_high_blood_pressurepngCreative Commons License associated httpcreativecommonsorglicensesby-sa30
bull 3 months Howevermdashwe have evidence of structural abnormalities Could potentially stage at G3b A3 (red on the heat map)
bull Goal blood pressure
bull JNC 8 14090 NKF 13080
bull Additional lab needed for progression monitoring
bull Cbc renal panel phos Vit D iPTH uric acid urine micro (we already have the renal sono and urine proteincr ratio and lipid)
Selective renal angiography (left lower renal artery) after successful percutaneous balloon dilatation of the stenotic lesionFibromuscular dysplasia in an accessory renal artery causing renovascular hypertension
Secondary Hypertension
Images retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileRenal_FMD2jpg and httpcommonswikimediaorgwikiFileRenal_FMDjpgCreative Commons License associated httpcreativecommonsorglicensesby20deeden (both images)
CASE 2bull OS is a 64year old Hispanic female in for DM check She has had DM for 15+ years and is currently
taking metformin 1000mg bid Lisinopril 10mg a day atorvastatin 40mg a day Labs today showed the following
bull Hgba1c 86 cmp eGFR 50 lipid WNL proteincr ratio 650mg These results are similar to her last visit
bull Upon further hx-you find that she had a recent eye exam and has mild nonproliferaive retinopathy She does not have neuropathy or other ss
bull What further workup do you need
bull Renal sonogram urine micro iPTH vit D (25 OH) phos uric acid
bull Dx stage
bull G3a A3
bull What further treatment do you need
bull Improve glycemic control Increase Lisinopril to 20mg with a goal of 40mg Avoid NSAIDs or other nephrotoxic agents make sure meds are renally dosed monitor 3xyear nephro referral
MANAGEMENT OF CKD IN DIABETESeGFR Recommended
All patients
Yearly measurement of creatinine urinary albumin excretion potassium
45-60 Referral to a nephrologist if possibility for nondiabetickidney disease existsConsider dose adjustment of medicationsMonitor eGFR every 6 monthsMonitor electrolytes bicarbonate hemoglobin calcium phosphorus parathyroid hormone at least yearly
Assure vitamin D sufficiencyConsider bone density testingReferral for dietary counselling
American Diabetes Association Standards of Medical Care in Diabetes Microvascular complications and foot care Diabetes Care 2017 40 (Suppl 1) S88-S98
CASE 3
bull 19 year old African American woman presents to your clinic with complaints of fatigue joint pains a new rash on her face oral ulcer
bull On exam BP 15080 P 88 Afebrile 96 O2 sats on RAbull GEN No respiratory distress at restbull HEENT painless oral ulcer flat rash over malar eminences sparing the nasolabial fold pallor +bull Lungs CTAbull CVS S1S2 regularbull Abdomen soft NTbull Ext left elbow joint and bilateral wrist joints are swollen and tender
bull What would you orderbull CBC CMP ua urine microscopy (microalbumin or urine proteincr ratio) ANA esr RF anti-ccp uric acid TSH
CASE 3
bull Working dx fatigue oral ulcer joint pain
bull Basic Labs Na 135 K 55 Bicarb 18 BUN 50 Cr 35 eGFR 22 Ca 90 ANA + titer 1640
bull UA 3+ blood 3+ protein RBC casts +
bull Given these results what is the most likely diagnosis
bull What would you do
SYSTEMIC LUPUS ERYTHEMATOSUS (SLE)
bull SLE multisystemic disease Etiology unknown
bull Production of autoantibodies and immune complexes formation
bull There is renal involvement in the great majority of patients with SLE at some time of the evolution 66-90
SLE ndash LUPUS NEPHRITIS
bull Race SLE is more commonsevere in African americans than Caucasiansbull
bull Gender female-to-male ratio of 91
bull Age Most patients develop lupus nephritis early in their disease course SLE is more common among women in the third decade of life and lupus nephritis occurs in patients aged 20-40 years
bull Kidney Biopsy For staging lupus nephritis (Class 1-5)
CASE 5bull A 80 year old man who has not seen a PCP in many years
presents to your clinic for weakness for the past few months On further questioning he tells you that his bones also have been hurting lately and he has developed leg swelling in the past month or so
bull On exam bull BP 16090 P 88 Afebrilebull GEN Thin built manbull HEENT pallor presentbull Lungs clearbull CVS S1S2 regular no rub or gallopbull Abdomen soft NTbull Ext 2 + edema
CASE 5
bull Differentials
bull CHF MI Cancer arthritis
bull Labs
bull CBC CMP urine microscopy urine proteincr ratio ESR TSH EKG BNP pa and lat CXR
bull LABS Urine dipstick negative for protein or blood
bull Basic chem bull Na 136 (135-145) K 51 (35-55) Chloride 108 (96-106) Bicarb 25
Given this presentation and the labs (low anion gap and elevated calcium anemia kidney failure) what will you think of What will you order next
Serum and urine protein electrophoresis
Intratubular refractile casts with surrounding syncytial giant cell reaction with chronic tubulointerstitial nephritis and fibrosis characteristic of myeloma cast nephropathy
Kidney Biopsy
CASE STUDYbull A 35 year old African American woman was seen in the clinic for
chronic cough and dyspnea on exertion She gave history of vague symptoms of fatigue and weight loss of 20 Ibs over the last six months
bull List some differentialsbull TB sarcoid lupus thyroid problems PEbull What would you orderbull PPD cbc cmp UA TSH ANA pa and lat cxr
bull Her labs were significant for mildly elevated calcium level and a creatinine of 20 mgdL eGFR 37
bull She had 750 mg of proteinuriaday
bull PPD neg ANA neg TSH and other labs WNL
bull Assuming this is present more than 3 monthshelliphellipwhat is her ckd stage
bull G3b A3
bull What do we still need
CT scan of chest
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileAnterior_mediastinal_mass_thymomajpgCreative Commons License associated httpcreativecommonsorglicensesby20deeden
CXR ndash HILAR LYMPHADENOPATHY
WHATS NEEDED NEXT
bull Biopsy of hilar lymphadenopathy or renal biopsy
bull DX sarcoidosis
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileSarcoidosis_signs_and_symptomsjpgThis work is in the public domain in the United States because it is a work of the United States Federal Government under the terms of Title 17 Chapter 1 Section 105 of the US Code
NEWLY DX CKD
bull 1) urinalysis microscopy ultrasound proteincr ratio
bull If obstruction-treat
bull No obstruction
bull Hx critical (consider myeloma if high risk)
bull glomerular bleeding or albumin in urine
bull Yes workup for glomerular causes (ANArf hep B C upep spep ANCA complement C3 C4)
bull No sterile pyruria-consider interstitial nephritis
bull High risk renovascular disease Evaluate renovascular disease
Additional Online Resources for CKD LearningbullNational Kidney Foundation wwwkidneyorgbullUnited States Renal Data Service wwwusrdsorgbullCDCrsquos CKD Surveillance Project
httpnccdcdcgovckdbullNational Kidney Disease Education Program
(NKDEP) httpnkdepnihgov
BIBLIOGRAPHY
bull Afzali B amp Goldsmith D J (2016 June 29) Statins and chronic kidney disease (G C Curhan amp A M Sheridan Eds) Retrieved 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsstatins-and-chronic-kidney-disease
bull American Diabetes Association Standards of Medical Care in Diabetes (2017) Microvascular complications and foot care Diabetes Care 2017 (40) S88-S98
bull American Diabetes Association Standards of Medical Care in Diabetes (2017) Microvascular complications and foot care Diabetes Care 40 (suppl 1) S88-S98
bull Berns J S (2017 Mar 22) Treatment of anemia in nondialysis chronic kidney disease (T A Golper amp A M Sheridan Eds) Retrieved from UpToDate httpswww-uptodate-comproxywichitaeducontentstreatment-of-anemia-in-nondialysis-chronic-kidney-disease
bull Chan M Dall A T Fletcher K E Lu N amp Trivedi H (2007) Outcomes in patients with chronic kidney disease referred late to nephrologists a meta-analysis American Journal of Medicine 120(12) 1063-1070
bull Coresh J Selvin E amp Stevens L A (2007) Prevalence of chronic kidny disease in the United States JAMA 298(17) doi101001jama298172038
bull de Brito-Ashurst I Varagunam M Raftery M amp Yagoob M (2009) Bicarbonate supplementation slows progression of CKD and improves nutritional status Journal of American Society of Nephrology (20) 2075-2084
BIBLIOGRAPHY
bull Duncan L Heathcoat J Djurdjev O amp Levin A (2001) Screening for renal disease using serum creatinine who are we missing Nephrology Dialysis and Transplant 16(5) 1042-1046
bull Dunkler D Gao P Lee S F Heinz G Clase C M Tobe S Oberbauer R (2015 August 7) Risk prediction for early CKD in type 2 diabetes Retrieved from Clinical Journal of the American Society of Nephrology httpcjasnasnjournalsorgcontent1081371fullsid=61422554-a5f1-41ac-b696-dcd3b12bd268
bull Fatehi P amp Chi-yuan H (September 15 2016) Diagnostic approach to the patient with newly identified chronic kidney disease (G C Curhan amp A M Sheridan Eds) Retrieved May 7 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsdiagnostic-approach-to-the-patient-with-newly-identified-chronic-kidney-disease
bull Fink J e (2009) Chronic Kidney Disease as an Under-Recognized Threat to Patient Safety American journal of kidney diseases the official journal of the National Kidney Foundation 53(4) 681-688
bull Gaffo A L amp Saag K G (2008 Nov) Management of hyperuricemia and gout in CKD doihttpdxdoiorg101053jajkd200807035
bull Hebert L A amp Parikh S V (2014 June 18) Differential diagnosis and evaluation of glomerular disease (R J Glassock amp A Q Lam Eds) Retrieved May 7 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsdifferential-diagnosis-and-evaluation-of-glomerular-disease
bull Inker L Perrone R D Sterns R H amp Forman J P (2017 March 7) Assessment of kidney function Retrieved from UpToDate httpswww-uptodate-comproxywichitaeducontentsassessment-of-kidney-functionsource=search_resultampsearch=creatinineampselectedTitle=1~150
BIBLIOGRAPHY
bull James P A Ortiz E amp Et Al (2014) Evidence based guideline for the management of high blood pressure in adults (JNC) JAMA 311(5) 507-520
bull Kidney Disease Improving Global Outcomes (KDIGO) CKD Work Group (2013 January) KDIGO 2012 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease Retrieved from Kidney International Supplement httpwwwkidney-internationalorg
bull Kunz R Friedrich C Wolbers M amp Mann J F (2008) Meta-analysis effect of monotherapy and combination therapy with inhibitors of the renin angiotensin system on proteinuria in renal disease Annals of Internal Medicine 148(1) 30-48
bull Levey A Stevens L A Schmid C H Castro A F Feldman H I Kusek J W Coresh J (2009) A new equation to estimate glomerular filtration rate Annals of Internal Medicine 150(9) 604-612
bull Levin A Bakris G L Molitch M Smulders M M Williams L A amp Andress D L (2007 Jan) Prevalence of abnormal serum vitamin D PTH calcium and phosphorus in patients with chronic kidney disease results of the study to evaluate early kidney disease Kidney International 71(1) 31-38 Retrieved from PubMED
bull Mahajan A Simoni J Sheather S Broglio K Rajab M amp Wesson D (2010) Daily oral sodium bicarbonate preserves glomerular filtration rate by slowing its decline in early hypertensive nephropathy Kidney International (78_ 303-309
bull Mann J Schmieder R E amp McQueen M (2008) Renal outcomes with telmisartan ramipril or both in people at high vascular risk (the ONTARGET study) a multicentre randomised doubleblind ocntrolled trial Lancet 372(9638) 547-533
BIBLIOGRAPHY
bull Matovinović M S (2009) Pathophysiology and classification of kidney disease Retrieved from The Journal of the International Federation of Clinical Chemistry and Laboratory Medicine httpwwwifccorgifccfilesdocs20010902pdf
bull Moe S Drueke T Lameire N amp Eknoyan G (2007 Jan) Chronic kidney disease-mineral-bone disorder a new paradigmdoi101053jackd200610005
bull Murtagh F E Marsh J E Donohoe P Ekbal N J Sheerin N S amp Harris F E (2007 July) Dialysis or not A comparative survival study of patients over 75 years with chronic kidney disease stage 5 Retrieved from Nephrology Dialysis and Transplant 22(7) httpswwwncbinlmnihgovpubmed17412702
bull National Kidney Foundation (2002) KDOQI clinical practice guidelines for chronic kidney disease evaluation classification andstratification American Journal of Kidney Disease S1-S266
bull National Kidney Foundation (2014 November 5) Fact Sheets Retrieved from httpwwwkidneyorgnewsnewsroomfactsheetsFastFacts
bull Pal S (2012 June 2) Trends in chronic kidney disease Retrieved from US Pharmacist (37)6 httpswwwuspharmacistcomarticletrends-in-chronic-kidney-disease
bull Qunibi W amp Henrich W L (2017 Jan 19) Overview of chronic kidney disease-mineral and bone disorder (J Berns amp A M Sheridan Eds) Retrieved from UpToDate httpswww-uptodate-comoverview-of-chronic-kidney-disease-mineral-and-bone-disorder-ckd-mbd
bull Rosenberg M (2016 Feb 24) Overview of the management of chronic kidney disease in adults (G C Curhan amp A M Sheridan Eds) Retrieved from UpToDate UpToDate httpswww-uptodate-comproxywichitaeducontentsoverview-of-the-management-of-chronic-kidney-disease-in-adults
BIBLIOGRAPHY
bull Szczech L Stewart R C Hsu-Lin S DeLosky R J Astor B C Fox C H Vassalotti J A (2014) Primary care detection of chronic kidney disease in adults with type 2 diabetes The ADD-CKD Study (Awareness Detection and Drug Therapy in type 2 diabetes and chronic kidney disease PLOS doihttpsdoiorg101371journalpone0110535
bull USRDS (2016) Annual data report 2016 Epidemiology of kidney disease in the United States Retrieved from United States Renal Data System httpswwwusrdsorgadraspx
bull Vasudev B amp Vasudev M (2012) A model curriculum for residents rotating in nephrology MedEDPORTAL doihttpdoiorg1015766mep_2374-82658288
bull Wei L MacDonald T M Jennings C Sheng X amp Flynn R W (2013) Estimated GFR reporting is associated with decreased nonsteroidal anti-inflammatory drug prescribing and increased renal function Kidney International (84)1 174-178
chronic kidney disease in primary care
CKD as a Public Health Issue
Slide Number 3
Costs of CKD in 2013 dollarsUSRDS report
Steps to CKD Patient Care
Renal anatomy and physiology
Definition of Chronic Kidney Disease
CKD Risk Factors
Gaps in CKD Diagnosis
Slide Number 10
Steps to CKD Patient Care
creatinine
Glomerular filtration rate
Slide Number 14
Slide Number 15
Use These Equations Cautiously if at all in hellip
lab albumin creatinine ratio
The New CKD Categories
Steps to CKD Patient Care
Slide Number 20
Kidney Involvement in Systemic Diseases
Slide Number 22
Slide Number 23
DysmorphicRenal Hematuria
Slide Number 25
If you have albuminuria or hematuria-order the following labs
DIABETIC NEPHROPATHY 1 CAUSE OF CKDbull Clinical syndromebull Albuminuria gt30 mg 24 hrsbull Proteinuria gt500 mg24 hrsbull Hypertension developsbull Progressive increase in proteinuriabull Progressive decline in glomerular filtration rate
bull Chronic kidney disease should be attributed to diabetic nephropathies in most patients with diabetes if albuminuria and diabetic retinopathy are both present other causes of CKD should be entertained if diabetic retinopathy is absent (KDIGO 2007)
DIABETIC NEPHROPATHY MORTALITY
bull After 40 yrs of DM
bull 10 alive if proteinuria is present
bull 70 alive if proteinuria is absent
bull Heart Disease is 15 times higher risk in those with proteinuria
bull Proteinuria = death in this population
Dunkler et al 2015
GOALS OF CARE IN CKD GLUCOSE CONTROL
bull Target HbA1c ~70 (lt695 greatest chance of reducing albuminuria)bull Can be extended above 70 with comorbidities or limited life expectancy and
risk of hypoglycemiabull Risk of hypoglycemia increases as kidney function becomes impairedbull Declining kidney function may necessitate changes to diabetes medications and
bull Just having HTN can cause proteinuriabull Usually 1-2 gms of protein a daybull Treat them like a diabetic with ACEI or ARBS and tight blood
pressure controlbull JNC-8 goal lt14090 for ptrsquos with CKDbull National kidney foundation lt14090 if ckd and no proteinuria
lt13080 if proteinuria present
(James Ortiz amp Et Al 2014)
TREATING HYPERTENSIONPROTEINURIA ACEI ORARBbull Riskbenefit should be carefully assessed in the elderly and medically fragilebull Check labs after initiation
bull If less than 30 SCr increase continue and monitorbull If more than 30 SCr increase stop ACEi and evaluate for renal artery stenosis
bull Continue until contraindication arises no absolute eGFR cutoffbull Better proteinuria suppression with low Na diet and diureticsbull Avoid volume depletionbull Avoid ACEi and ARB in combination12
bull Risk of adverse events (impaired kidney function hyperkalemia)
(Kunz Friedrich Wolbers amp Mann 2008)(Mann Schmieder amp McQueen 2008)
bull In adults gt50 yrs statin when eGFR ge 60 mlmin173m2 statin or statinezetimibe combination when eGFR lt 60 mlmin173m2
bull In adults lt 50 yrs statin if history of known CAD MI DM strokebull Aspirin is indicated for secondary but not primary prevention
Kidney Disease Improving Global Outcomes (KDIGO) CKD Work Group Kidney Int Suppls 201331-150
STATINS-RENOPROTECTIVECONTROVERSY
bull HMG-CoA reductase inhibitors (statins) in high doses can cause proteinuria
bull Possibly associated with less inflammation endothelial dysfunction and scarring in the kidney because they also block inflammatory cytokines
bull Use statins for CV disease not to treat proteinuria
(Afzali and Goldsmith 2016)
MEDICINE CAUTION
bull Hold metformin when gfr lt35 mlmin
bull GFR lt50 mlmin should alert to check all doses of meds
bull No bisphosphanates lt35 mlmin
bull No NSAIDScox 2 inhibitors lt60 mlmin
bull Atenolol ndashrenal excretion
bull BACTRIM A lot of AKI
MEDICINE CAUTION
bull Lovenox-use subcut heparinbull Apixibanbull Dabigatranbull Rivaroxibanbull Lithiumbull GABAPENTIN (ckd 4 max 300mg qd ckd 5 max 300mg qod)
STEPS TO CKD PATIENT CARE
1 CKD definition and risks2 Assess GFR albuminuria3 Determine etiology4 Assess for evidence of progression5 Assess for associated complications6 Discuss dialysistransplantation
CKD-CVD-DIABETES LINK CKD IS A DISEASE MULTIPLIER
National kidney foundation 2014
KDIGO 2017
CKD-MINERAL BONE DISORDERS
bull As kidneys fail they
bull Stop activating calcitriol (the active form of Vit D)mdashcausing calcium imbalance
bull Do not remove phosphorus from bloodmdashleading to phosphorus retention
bull The extra phosphorus pulls calcium out of bones causing them to weaken
bull High phosphorus stimulates PTH release
bull These changes (plus others) cause the start of secondary hyperparathyroidism
bull Labs
bull eGFR
bull Calcium
bull Phos
bull Vit D
bull iPTH
(Qunibi amp Henrich 2017)
PREVALENCE OF ABNORMALITIES OF MINERAL METABOLISM PTH IN CKD
bull Progression of disease ndash declining eGFR increasing proteinuria
bull Degree of proteinuria nephrotic syndrome gt 05-10 gd on ACEi or ARB therapy
bull Etiology of CKD not certain
bull Need help with disease management
bull Indications for kidney biopsy
Rosenberg 2016
WHEN TO REFER
STEPS TO CKD PATIENT CARE
1 CKD definition and risks2 Assess GFR albuminuria3 Determine etiology4 Assess for evidence of progression5 Assess for associated complications6 Discuss dialysistransplantation
KIDNEY TRANSPLANTATION
bull Treatment of choice for ESRDbull Improves quality of lifebull Waiting list time varies-3-5 yearsbull 3 year survival rate after transplantation is 83-94bull Increased risk of cancer
STARTING DIALYSIS IN THE ELDERLYhellipOR NOT
bull Among patients gt 75 yrs with stage 5 CKD who chose to NOT start dialysisbull Overall more likely to die over next 1-2 years bull But if they had ischemic heart disease or other significant comorbidity NO
DIFFERENCE in survival
bull Active disease management and supportive care may be appropriate without starting dialysis in the ill elderly
bull Palliative care does not mean ldquono carerdquo
bull Must have end-of-life discussions
(Murtagh et al 2007)
CKD MANAGEMENTbull Diagnose cause and treat underlying conditionbull Stage per guidelinesbull Slow progression of kidney disease (ACE inhibitors)bull Monitor for complicationsmdashvolume overload hyperkalemia metabolic acidosis
hyperphosphatemia anorexia fatigue htn bone diseasebull Labs cmp cbc phos Vit D 25OH iPTH urine microscopy uric acid urine
proteincr ratio-frequency based off heat map Get sono at least oncebull Vaccinate influenza hep B pneumococcalbull Eval ASCVD risk-likely needs statinbull Possible dexa (donrsquot give bisphosphonates if GFRlt35 let specialist manage)bull Refer to nephrology when eGFR is lt30 (sometimes if higher risk-refer earlier)
CASE 1
bull 55 year old man with past medical history of headaches presents to your office for his first time visit to a PCP in over 30 years
bull He has no past history of being admitted to the hospital and he does not take any OTC medsNSAIDsherbal meds He has no history of ETOH abuse smoking or drug use
bull Vitals BP 180100 mmHg pulse 80 R 18
bull Exam No JVD S1S2 regular PMI shifted to the left no gallop no abdominal bruit pulses bilaterally equal and regular no leg edema
bull What would you order
bull EKG cbc cmp ua urine proteincr ratio lipid
LAB RESULTS
bull Labs reveal a creatinine of 22 mgdL eGFR 33 Urine shows no blood or casts Urineprotein ratio shows 1 gm protein24 hrs EKG shows LVH
bull Next step in workupbull Renal ultrasound 1st then SPEP UPEP with immunofixation serum free light chains
bull Additional labs neg Renal ultrasound shows that both kidneys are slightly reduced in size and are mildly echogenic with no mass or hydronephrosis
bull What is your diagnosis
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileMain_complications_of_persistent_high_blood_pressurepngCreative Commons License associated httpcreativecommonsorglicensesby-sa30
bull 3 months Howevermdashwe have evidence of structural abnormalities Could potentially stage at G3b A3 (red on the heat map)
bull Goal blood pressure
bull JNC 8 14090 NKF 13080
bull Additional lab needed for progression monitoring
bull Cbc renal panel phos Vit D iPTH uric acid urine micro (we already have the renal sono and urine proteincr ratio and lipid)
Selective renal angiography (left lower renal artery) after successful percutaneous balloon dilatation of the stenotic lesionFibromuscular dysplasia in an accessory renal artery causing renovascular hypertension
Secondary Hypertension
Images retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileRenal_FMD2jpg and httpcommonswikimediaorgwikiFileRenal_FMDjpgCreative Commons License associated httpcreativecommonsorglicensesby20deeden (both images)
CASE 2bull OS is a 64year old Hispanic female in for DM check She has had DM for 15+ years and is currently
taking metformin 1000mg bid Lisinopril 10mg a day atorvastatin 40mg a day Labs today showed the following
bull Hgba1c 86 cmp eGFR 50 lipid WNL proteincr ratio 650mg These results are similar to her last visit
bull Upon further hx-you find that she had a recent eye exam and has mild nonproliferaive retinopathy She does not have neuropathy or other ss
bull What further workup do you need
bull Renal sonogram urine micro iPTH vit D (25 OH) phos uric acid
bull Dx stage
bull G3a A3
bull What further treatment do you need
bull Improve glycemic control Increase Lisinopril to 20mg with a goal of 40mg Avoid NSAIDs or other nephrotoxic agents make sure meds are renally dosed monitor 3xyear nephro referral
MANAGEMENT OF CKD IN DIABETESeGFR Recommended
All patients
Yearly measurement of creatinine urinary albumin excretion potassium
45-60 Referral to a nephrologist if possibility for nondiabetickidney disease existsConsider dose adjustment of medicationsMonitor eGFR every 6 monthsMonitor electrolytes bicarbonate hemoglobin calcium phosphorus parathyroid hormone at least yearly
Assure vitamin D sufficiencyConsider bone density testingReferral for dietary counselling
American Diabetes Association Standards of Medical Care in Diabetes Microvascular complications and foot care Diabetes Care 2017 40 (Suppl 1) S88-S98
CASE 3
bull 19 year old African American woman presents to your clinic with complaints of fatigue joint pains a new rash on her face oral ulcer
bull On exam BP 15080 P 88 Afebrile 96 O2 sats on RAbull GEN No respiratory distress at restbull HEENT painless oral ulcer flat rash over malar eminences sparing the nasolabial fold pallor +bull Lungs CTAbull CVS S1S2 regularbull Abdomen soft NTbull Ext left elbow joint and bilateral wrist joints are swollen and tender
bull What would you orderbull CBC CMP ua urine microscopy (microalbumin or urine proteincr ratio) ANA esr RF anti-ccp uric acid TSH
CASE 3
bull Working dx fatigue oral ulcer joint pain
bull Basic Labs Na 135 K 55 Bicarb 18 BUN 50 Cr 35 eGFR 22 Ca 90 ANA + titer 1640
bull UA 3+ blood 3+ protein RBC casts +
bull Given these results what is the most likely diagnosis
bull What would you do
SYSTEMIC LUPUS ERYTHEMATOSUS (SLE)
bull SLE multisystemic disease Etiology unknown
bull Production of autoantibodies and immune complexes formation
bull There is renal involvement in the great majority of patients with SLE at some time of the evolution 66-90
SLE ndash LUPUS NEPHRITIS
bull Race SLE is more commonsevere in African americans than Caucasiansbull
bull Gender female-to-male ratio of 91
bull Age Most patients develop lupus nephritis early in their disease course SLE is more common among women in the third decade of life and lupus nephritis occurs in patients aged 20-40 years
bull Kidney Biopsy For staging lupus nephritis (Class 1-5)
CASE 5bull A 80 year old man who has not seen a PCP in many years
presents to your clinic for weakness for the past few months On further questioning he tells you that his bones also have been hurting lately and he has developed leg swelling in the past month or so
bull On exam bull BP 16090 P 88 Afebrilebull GEN Thin built manbull HEENT pallor presentbull Lungs clearbull CVS S1S2 regular no rub or gallopbull Abdomen soft NTbull Ext 2 + edema
CASE 5
bull Differentials
bull CHF MI Cancer arthritis
bull Labs
bull CBC CMP urine microscopy urine proteincr ratio ESR TSH EKG BNP pa and lat CXR
bull LABS Urine dipstick negative for protein or blood
bull Basic chem bull Na 136 (135-145) K 51 (35-55) Chloride 108 (96-106) Bicarb 25
Given this presentation and the labs (low anion gap and elevated calcium anemia kidney failure) what will you think of What will you order next
Serum and urine protein electrophoresis
Intratubular refractile casts with surrounding syncytial giant cell reaction with chronic tubulointerstitial nephritis and fibrosis characteristic of myeloma cast nephropathy
Kidney Biopsy
CASE STUDYbull A 35 year old African American woman was seen in the clinic for
chronic cough and dyspnea on exertion She gave history of vague symptoms of fatigue and weight loss of 20 Ibs over the last six months
bull List some differentialsbull TB sarcoid lupus thyroid problems PEbull What would you orderbull PPD cbc cmp UA TSH ANA pa and lat cxr
bull Her labs were significant for mildly elevated calcium level and a creatinine of 20 mgdL eGFR 37
bull She had 750 mg of proteinuriaday
bull PPD neg ANA neg TSH and other labs WNL
bull Assuming this is present more than 3 monthshelliphellipwhat is her ckd stage
bull G3b A3
bull What do we still need
CT scan of chest
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileAnterior_mediastinal_mass_thymomajpgCreative Commons License associated httpcreativecommonsorglicensesby20deeden
CXR ndash HILAR LYMPHADENOPATHY
WHATS NEEDED NEXT
bull Biopsy of hilar lymphadenopathy or renal biopsy
bull DX sarcoidosis
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileSarcoidosis_signs_and_symptomsjpgThis work is in the public domain in the United States because it is a work of the United States Federal Government under the terms of Title 17 Chapter 1 Section 105 of the US Code
NEWLY DX CKD
bull 1) urinalysis microscopy ultrasound proteincr ratio
bull If obstruction-treat
bull No obstruction
bull Hx critical (consider myeloma if high risk)
bull glomerular bleeding or albumin in urine
bull Yes workup for glomerular causes (ANArf hep B C upep spep ANCA complement C3 C4)
bull No sterile pyruria-consider interstitial nephritis
bull High risk renovascular disease Evaluate renovascular disease
Additional Online Resources for CKD LearningbullNational Kidney Foundation wwwkidneyorgbullUnited States Renal Data Service wwwusrdsorgbullCDCrsquos CKD Surveillance Project
httpnccdcdcgovckdbullNational Kidney Disease Education Program
(NKDEP) httpnkdepnihgov
BIBLIOGRAPHY
bull Afzali B amp Goldsmith D J (2016 June 29) Statins and chronic kidney disease (G C Curhan amp A M Sheridan Eds) Retrieved 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsstatins-and-chronic-kidney-disease
bull American Diabetes Association Standards of Medical Care in Diabetes (2017) Microvascular complications and foot care Diabetes Care 2017 (40) S88-S98
bull American Diabetes Association Standards of Medical Care in Diabetes (2017) Microvascular complications and foot care Diabetes Care 40 (suppl 1) S88-S98
bull Berns J S (2017 Mar 22) Treatment of anemia in nondialysis chronic kidney disease (T A Golper amp A M Sheridan Eds) Retrieved from UpToDate httpswww-uptodate-comproxywichitaeducontentstreatment-of-anemia-in-nondialysis-chronic-kidney-disease
bull Chan M Dall A T Fletcher K E Lu N amp Trivedi H (2007) Outcomes in patients with chronic kidney disease referred late to nephrologists a meta-analysis American Journal of Medicine 120(12) 1063-1070
bull Coresh J Selvin E amp Stevens L A (2007) Prevalence of chronic kidny disease in the United States JAMA 298(17) doi101001jama298172038
bull de Brito-Ashurst I Varagunam M Raftery M amp Yagoob M (2009) Bicarbonate supplementation slows progression of CKD and improves nutritional status Journal of American Society of Nephrology (20) 2075-2084
BIBLIOGRAPHY
bull Duncan L Heathcoat J Djurdjev O amp Levin A (2001) Screening for renal disease using serum creatinine who are we missing Nephrology Dialysis and Transplant 16(5) 1042-1046
bull Dunkler D Gao P Lee S F Heinz G Clase C M Tobe S Oberbauer R (2015 August 7) Risk prediction for early CKD in type 2 diabetes Retrieved from Clinical Journal of the American Society of Nephrology httpcjasnasnjournalsorgcontent1081371fullsid=61422554-a5f1-41ac-b696-dcd3b12bd268
bull Fatehi P amp Chi-yuan H (September 15 2016) Diagnostic approach to the patient with newly identified chronic kidney disease (G C Curhan amp A M Sheridan Eds) Retrieved May 7 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsdiagnostic-approach-to-the-patient-with-newly-identified-chronic-kidney-disease
bull Fink J e (2009) Chronic Kidney Disease as an Under-Recognized Threat to Patient Safety American journal of kidney diseases the official journal of the National Kidney Foundation 53(4) 681-688
bull Gaffo A L amp Saag K G (2008 Nov) Management of hyperuricemia and gout in CKD doihttpdxdoiorg101053jajkd200807035
bull Hebert L A amp Parikh S V (2014 June 18) Differential diagnosis and evaluation of glomerular disease (R J Glassock amp A Q Lam Eds) Retrieved May 7 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsdifferential-diagnosis-and-evaluation-of-glomerular-disease
bull Inker L Perrone R D Sterns R H amp Forman J P (2017 March 7) Assessment of kidney function Retrieved from UpToDate httpswww-uptodate-comproxywichitaeducontentsassessment-of-kidney-functionsource=search_resultampsearch=creatinineampselectedTitle=1~150
BIBLIOGRAPHY
bull James P A Ortiz E amp Et Al (2014) Evidence based guideline for the management of high blood pressure in adults (JNC) JAMA 311(5) 507-520
bull Kidney Disease Improving Global Outcomes (KDIGO) CKD Work Group (2013 January) KDIGO 2012 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease Retrieved from Kidney International Supplement httpwwwkidney-internationalorg
bull Kunz R Friedrich C Wolbers M amp Mann J F (2008) Meta-analysis effect of monotherapy and combination therapy with inhibitors of the renin angiotensin system on proteinuria in renal disease Annals of Internal Medicine 148(1) 30-48
bull Levey A Stevens L A Schmid C H Castro A F Feldman H I Kusek J W Coresh J (2009) A new equation to estimate glomerular filtration rate Annals of Internal Medicine 150(9) 604-612
bull Levin A Bakris G L Molitch M Smulders M M Williams L A amp Andress D L (2007 Jan) Prevalence of abnormal serum vitamin D PTH calcium and phosphorus in patients with chronic kidney disease results of the study to evaluate early kidney disease Kidney International 71(1) 31-38 Retrieved from PubMED
bull Mahajan A Simoni J Sheather S Broglio K Rajab M amp Wesson D (2010) Daily oral sodium bicarbonate preserves glomerular filtration rate by slowing its decline in early hypertensive nephropathy Kidney International (78_ 303-309
bull Mann J Schmieder R E amp McQueen M (2008) Renal outcomes with telmisartan ramipril or both in people at high vascular risk (the ONTARGET study) a multicentre randomised doubleblind ocntrolled trial Lancet 372(9638) 547-533
BIBLIOGRAPHY
bull Matovinović M S (2009) Pathophysiology and classification of kidney disease Retrieved from The Journal of the International Federation of Clinical Chemistry and Laboratory Medicine httpwwwifccorgifccfilesdocs20010902pdf
bull Moe S Drueke T Lameire N amp Eknoyan G (2007 Jan) Chronic kidney disease-mineral-bone disorder a new paradigmdoi101053jackd200610005
bull Murtagh F E Marsh J E Donohoe P Ekbal N J Sheerin N S amp Harris F E (2007 July) Dialysis or not A comparative survival study of patients over 75 years with chronic kidney disease stage 5 Retrieved from Nephrology Dialysis and Transplant 22(7) httpswwwncbinlmnihgovpubmed17412702
bull National Kidney Foundation (2002) KDOQI clinical practice guidelines for chronic kidney disease evaluation classification andstratification American Journal of Kidney Disease S1-S266
bull National Kidney Foundation (2014 November 5) Fact Sheets Retrieved from httpwwwkidneyorgnewsnewsroomfactsheetsFastFacts
bull Pal S (2012 June 2) Trends in chronic kidney disease Retrieved from US Pharmacist (37)6 httpswwwuspharmacistcomarticletrends-in-chronic-kidney-disease
bull Qunibi W amp Henrich W L (2017 Jan 19) Overview of chronic kidney disease-mineral and bone disorder (J Berns amp A M Sheridan Eds) Retrieved from UpToDate httpswww-uptodate-comoverview-of-chronic-kidney-disease-mineral-and-bone-disorder-ckd-mbd
bull Rosenberg M (2016 Feb 24) Overview of the management of chronic kidney disease in adults (G C Curhan amp A M Sheridan Eds) Retrieved from UpToDate UpToDate httpswww-uptodate-comproxywichitaeducontentsoverview-of-the-management-of-chronic-kidney-disease-in-adults
BIBLIOGRAPHY
bull Szczech L Stewart R C Hsu-Lin S DeLosky R J Astor B C Fox C H Vassalotti J A (2014) Primary care detection of chronic kidney disease in adults with type 2 diabetes The ADD-CKD Study (Awareness Detection and Drug Therapy in type 2 diabetes and chronic kidney disease PLOS doihttpsdoiorg101371journalpone0110535
bull USRDS (2016) Annual data report 2016 Epidemiology of kidney disease in the United States Retrieved from United States Renal Data System httpswwwusrdsorgadraspx
bull Vasudev B amp Vasudev M (2012) A model curriculum for residents rotating in nephrology MedEDPORTAL doihttpdoiorg1015766mep_2374-82658288
bull Wei L MacDonald T M Jennings C Sheng X amp Flynn R W (2013) Estimated GFR reporting is associated with decreased nonsteroidal anti-inflammatory drug prescribing and increased renal function Kidney International (84)1 174-178
chronic kidney disease in primary care
CKD as a Public Health Issue
Slide Number 3
Costs of CKD in 2013 dollarsUSRDS report
Steps to CKD Patient Care
Renal anatomy and physiology
Definition of Chronic Kidney Disease
CKD Risk Factors
Gaps in CKD Diagnosis
Slide Number 10
Steps to CKD Patient Care
creatinine
Glomerular filtration rate
Slide Number 14
Slide Number 15
Use These Equations Cautiously if at all in hellip
lab albumin creatinine ratio
The New CKD Categories
Steps to CKD Patient Care
Slide Number 20
Kidney Involvement in Systemic Diseases
Slide Number 22
Slide Number 23
DysmorphicRenal Hematuria
Slide Number 25
If you have albuminuria or hematuria-order the following labs
DIABETIC NEPHROPATHY 1 CAUSE OF CKDbull Clinical syndromebull Albuminuria gt30 mg 24 hrsbull Proteinuria gt500 mg24 hrsbull Hypertension developsbull Progressive increase in proteinuriabull Progressive decline in glomerular filtration rate
bull Chronic kidney disease should be attributed to diabetic nephropathies in most patients with diabetes if albuminuria and diabetic retinopathy are both present other causes of CKD should be entertained if diabetic retinopathy is absent (KDIGO 2007)
DIABETIC NEPHROPATHY MORTALITY
bull After 40 yrs of DM
bull 10 alive if proteinuria is present
bull 70 alive if proteinuria is absent
bull Heart Disease is 15 times higher risk in those with proteinuria
bull Proteinuria = death in this population
Dunkler et al 2015
GOALS OF CARE IN CKD GLUCOSE CONTROL
bull Target HbA1c ~70 (lt695 greatest chance of reducing albuminuria)bull Can be extended above 70 with comorbidities or limited life expectancy and
risk of hypoglycemiabull Risk of hypoglycemia increases as kidney function becomes impairedbull Declining kidney function may necessitate changes to diabetes medications and
bull Just having HTN can cause proteinuriabull Usually 1-2 gms of protein a daybull Treat them like a diabetic with ACEI or ARBS and tight blood
pressure controlbull JNC-8 goal lt14090 for ptrsquos with CKDbull National kidney foundation lt14090 if ckd and no proteinuria
lt13080 if proteinuria present
(James Ortiz amp Et Al 2014)
TREATING HYPERTENSIONPROTEINURIA ACEI ORARBbull Riskbenefit should be carefully assessed in the elderly and medically fragilebull Check labs after initiation
bull If less than 30 SCr increase continue and monitorbull If more than 30 SCr increase stop ACEi and evaluate for renal artery stenosis
bull Continue until contraindication arises no absolute eGFR cutoffbull Better proteinuria suppression with low Na diet and diureticsbull Avoid volume depletionbull Avoid ACEi and ARB in combination12
bull Risk of adverse events (impaired kidney function hyperkalemia)
(Kunz Friedrich Wolbers amp Mann 2008)(Mann Schmieder amp McQueen 2008)
bull In adults gt50 yrs statin when eGFR ge 60 mlmin173m2 statin or statinezetimibe combination when eGFR lt 60 mlmin173m2
bull In adults lt 50 yrs statin if history of known CAD MI DM strokebull Aspirin is indicated for secondary but not primary prevention
Kidney Disease Improving Global Outcomes (KDIGO) CKD Work Group Kidney Int Suppls 201331-150
STATINS-RENOPROTECTIVECONTROVERSY
bull HMG-CoA reductase inhibitors (statins) in high doses can cause proteinuria
bull Possibly associated with less inflammation endothelial dysfunction and scarring in the kidney because they also block inflammatory cytokines
bull Use statins for CV disease not to treat proteinuria
(Afzali and Goldsmith 2016)
MEDICINE CAUTION
bull Hold metformin when gfr lt35 mlmin
bull GFR lt50 mlmin should alert to check all doses of meds
bull No bisphosphanates lt35 mlmin
bull No NSAIDScox 2 inhibitors lt60 mlmin
bull Atenolol ndashrenal excretion
bull BACTRIM A lot of AKI
MEDICINE CAUTION
bull Lovenox-use subcut heparinbull Apixibanbull Dabigatranbull Rivaroxibanbull Lithiumbull GABAPENTIN (ckd 4 max 300mg qd ckd 5 max 300mg qod)
STEPS TO CKD PATIENT CARE
1 CKD definition and risks2 Assess GFR albuminuria3 Determine etiology4 Assess for evidence of progression5 Assess for associated complications6 Discuss dialysistransplantation
CKD-CVD-DIABETES LINK CKD IS A DISEASE MULTIPLIER
National kidney foundation 2014
KDIGO 2017
CKD-MINERAL BONE DISORDERS
bull As kidneys fail they
bull Stop activating calcitriol (the active form of Vit D)mdashcausing calcium imbalance
bull Do not remove phosphorus from bloodmdashleading to phosphorus retention
bull The extra phosphorus pulls calcium out of bones causing them to weaken
bull High phosphorus stimulates PTH release
bull These changes (plus others) cause the start of secondary hyperparathyroidism
bull Labs
bull eGFR
bull Calcium
bull Phos
bull Vit D
bull iPTH
(Qunibi amp Henrich 2017)
PREVALENCE OF ABNORMALITIES OF MINERAL METABOLISM PTH IN CKD
bull Progression of disease ndash declining eGFR increasing proteinuria
bull Degree of proteinuria nephrotic syndrome gt 05-10 gd on ACEi or ARB therapy
bull Etiology of CKD not certain
bull Need help with disease management
bull Indications for kidney biopsy
Rosenberg 2016
WHEN TO REFER
STEPS TO CKD PATIENT CARE
1 CKD definition and risks2 Assess GFR albuminuria3 Determine etiology4 Assess for evidence of progression5 Assess for associated complications6 Discuss dialysistransplantation
KIDNEY TRANSPLANTATION
bull Treatment of choice for ESRDbull Improves quality of lifebull Waiting list time varies-3-5 yearsbull 3 year survival rate after transplantation is 83-94bull Increased risk of cancer
STARTING DIALYSIS IN THE ELDERLYhellipOR NOT
bull Among patients gt 75 yrs with stage 5 CKD who chose to NOT start dialysisbull Overall more likely to die over next 1-2 years bull But if they had ischemic heart disease or other significant comorbidity NO
DIFFERENCE in survival
bull Active disease management and supportive care may be appropriate without starting dialysis in the ill elderly
bull Palliative care does not mean ldquono carerdquo
bull Must have end-of-life discussions
(Murtagh et al 2007)
CKD MANAGEMENTbull Diagnose cause and treat underlying conditionbull Stage per guidelinesbull Slow progression of kidney disease (ACE inhibitors)bull Monitor for complicationsmdashvolume overload hyperkalemia metabolic acidosis
hyperphosphatemia anorexia fatigue htn bone diseasebull Labs cmp cbc phos Vit D 25OH iPTH urine microscopy uric acid urine
proteincr ratio-frequency based off heat map Get sono at least oncebull Vaccinate influenza hep B pneumococcalbull Eval ASCVD risk-likely needs statinbull Possible dexa (donrsquot give bisphosphonates if GFRlt35 let specialist manage)bull Refer to nephrology when eGFR is lt30 (sometimes if higher risk-refer earlier)
CASE 1
bull 55 year old man with past medical history of headaches presents to your office for his first time visit to a PCP in over 30 years
bull He has no past history of being admitted to the hospital and he does not take any OTC medsNSAIDsherbal meds He has no history of ETOH abuse smoking or drug use
bull Vitals BP 180100 mmHg pulse 80 R 18
bull Exam No JVD S1S2 regular PMI shifted to the left no gallop no abdominal bruit pulses bilaterally equal and regular no leg edema
bull What would you order
bull EKG cbc cmp ua urine proteincr ratio lipid
LAB RESULTS
bull Labs reveal a creatinine of 22 mgdL eGFR 33 Urine shows no blood or casts Urineprotein ratio shows 1 gm protein24 hrs EKG shows LVH
bull Next step in workupbull Renal ultrasound 1st then SPEP UPEP with immunofixation serum free light chains
bull Additional labs neg Renal ultrasound shows that both kidneys are slightly reduced in size and are mildly echogenic with no mass or hydronephrosis
bull What is your diagnosis
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileMain_complications_of_persistent_high_blood_pressurepngCreative Commons License associated httpcreativecommonsorglicensesby-sa30
bull 3 months Howevermdashwe have evidence of structural abnormalities Could potentially stage at G3b A3 (red on the heat map)
bull Goal blood pressure
bull JNC 8 14090 NKF 13080
bull Additional lab needed for progression monitoring
bull Cbc renal panel phos Vit D iPTH uric acid urine micro (we already have the renal sono and urine proteincr ratio and lipid)
Selective renal angiography (left lower renal artery) after successful percutaneous balloon dilatation of the stenotic lesionFibromuscular dysplasia in an accessory renal artery causing renovascular hypertension
Secondary Hypertension
Images retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileRenal_FMD2jpg and httpcommonswikimediaorgwikiFileRenal_FMDjpgCreative Commons License associated httpcreativecommonsorglicensesby20deeden (both images)
CASE 2bull OS is a 64year old Hispanic female in for DM check She has had DM for 15+ years and is currently
taking metformin 1000mg bid Lisinopril 10mg a day atorvastatin 40mg a day Labs today showed the following
bull Hgba1c 86 cmp eGFR 50 lipid WNL proteincr ratio 650mg These results are similar to her last visit
bull Upon further hx-you find that she had a recent eye exam and has mild nonproliferaive retinopathy She does not have neuropathy or other ss
bull What further workup do you need
bull Renal sonogram urine micro iPTH vit D (25 OH) phos uric acid
bull Dx stage
bull G3a A3
bull What further treatment do you need
bull Improve glycemic control Increase Lisinopril to 20mg with a goal of 40mg Avoid NSAIDs or other nephrotoxic agents make sure meds are renally dosed monitor 3xyear nephro referral
MANAGEMENT OF CKD IN DIABETESeGFR Recommended
All patients
Yearly measurement of creatinine urinary albumin excretion potassium
45-60 Referral to a nephrologist if possibility for nondiabetickidney disease existsConsider dose adjustment of medicationsMonitor eGFR every 6 monthsMonitor electrolytes bicarbonate hemoglobin calcium phosphorus parathyroid hormone at least yearly
Assure vitamin D sufficiencyConsider bone density testingReferral for dietary counselling
American Diabetes Association Standards of Medical Care in Diabetes Microvascular complications and foot care Diabetes Care 2017 40 (Suppl 1) S88-S98
CASE 3
bull 19 year old African American woman presents to your clinic with complaints of fatigue joint pains a new rash on her face oral ulcer
bull On exam BP 15080 P 88 Afebrile 96 O2 sats on RAbull GEN No respiratory distress at restbull HEENT painless oral ulcer flat rash over malar eminences sparing the nasolabial fold pallor +bull Lungs CTAbull CVS S1S2 regularbull Abdomen soft NTbull Ext left elbow joint and bilateral wrist joints are swollen and tender
bull What would you orderbull CBC CMP ua urine microscopy (microalbumin or urine proteincr ratio) ANA esr RF anti-ccp uric acid TSH
CASE 3
bull Working dx fatigue oral ulcer joint pain
bull Basic Labs Na 135 K 55 Bicarb 18 BUN 50 Cr 35 eGFR 22 Ca 90 ANA + titer 1640
bull UA 3+ blood 3+ protein RBC casts +
bull Given these results what is the most likely diagnosis
bull What would you do
SYSTEMIC LUPUS ERYTHEMATOSUS (SLE)
bull SLE multisystemic disease Etiology unknown
bull Production of autoantibodies and immune complexes formation
bull There is renal involvement in the great majority of patients with SLE at some time of the evolution 66-90
SLE ndash LUPUS NEPHRITIS
bull Race SLE is more commonsevere in African americans than Caucasiansbull
bull Gender female-to-male ratio of 91
bull Age Most patients develop lupus nephritis early in their disease course SLE is more common among women in the third decade of life and lupus nephritis occurs in patients aged 20-40 years
bull Kidney Biopsy For staging lupus nephritis (Class 1-5)
CASE 5bull A 80 year old man who has not seen a PCP in many years
presents to your clinic for weakness for the past few months On further questioning he tells you that his bones also have been hurting lately and he has developed leg swelling in the past month or so
bull On exam bull BP 16090 P 88 Afebrilebull GEN Thin built manbull HEENT pallor presentbull Lungs clearbull CVS S1S2 regular no rub or gallopbull Abdomen soft NTbull Ext 2 + edema
CASE 5
bull Differentials
bull CHF MI Cancer arthritis
bull Labs
bull CBC CMP urine microscopy urine proteincr ratio ESR TSH EKG BNP pa and lat CXR
bull LABS Urine dipstick negative for protein or blood
bull Basic chem bull Na 136 (135-145) K 51 (35-55) Chloride 108 (96-106) Bicarb 25
Given this presentation and the labs (low anion gap and elevated calcium anemia kidney failure) what will you think of What will you order next
Serum and urine protein electrophoresis
Intratubular refractile casts with surrounding syncytial giant cell reaction with chronic tubulointerstitial nephritis and fibrosis characteristic of myeloma cast nephropathy
Kidney Biopsy
CASE STUDYbull A 35 year old African American woman was seen in the clinic for
chronic cough and dyspnea on exertion She gave history of vague symptoms of fatigue and weight loss of 20 Ibs over the last six months
bull List some differentialsbull TB sarcoid lupus thyroid problems PEbull What would you orderbull PPD cbc cmp UA TSH ANA pa and lat cxr
bull Her labs were significant for mildly elevated calcium level and a creatinine of 20 mgdL eGFR 37
bull She had 750 mg of proteinuriaday
bull PPD neg ANA neg TSH and other labs WNL
bull Assuming this is present more than 3 monthshelliphellipwhat is her ckd stage
bull G3b A3
bull What do we still need
CT scan of chest
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileAnterior_mediastinal_mass_thymomajpgCreative Commons License associated httpcreativecommonsorglicensesby20deeden
CXR ndash HILAR LYMPHADENOPATHY
WHATS NEEDED NEXT
bull Biopsy of hilar lymphadenopathy or renal biopsy
bull DX sarcoidosis
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileSarcoidosis_signs_and_symptomsjpgThis work is in the public domain in the United States because it is a work of the United States Federal Government under the terms of Title 17 Chapter 1 Section 105 of the US Code
NEWLY DX CKD
bull 1) urinalysis microscopy ultrasound proteincr ratio
bull If obstruction-treat
bull No obstruction
bull Hx critical (consider myeloma if high risk)
bull glomerular bleeding or albumin in urine
bull Yes workup for glomerular causes (ANArf hep B C upep spep ANCA complement C3 C4)
bull No sterile pyruria-consider interstitial nephritis
bull High risk renovascular disease Evaluate renovascular disease
Additional Online Resources for CKD LearningbullNational Kidney Foundation wwwkidneyorgbullUnited States Renal Data Service wwwusrdsorgbullCDCrsquos CKD Surveillance Project
httpnccdcdcgovckdbullNational Kidney Disease Education Program
(NKDEP) httpnkdepnihgov
BIBLIOGRAPHY
bull Afzali B amp Goldsmith D J (2016 June 29) Statins and chronic kidney disease (G C Curhan amp A M Sheridan Eds) Retrieved 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsstatins-and-chronic-kidney-disease
bull American Diabetes Association Standards of Medical Care in Diabetes (2017) Microvascular complications and foot care Diabetes Care 2017 (40) S88-S98
bull American Diabetes Association Standards of Medical Care in Diabetes (2017) Microvascular complications and foot care Diabetes Care 40 (suppl 1) S88-S98
bull Berns J S (2017 Mar 22) Treatment of anemia in nondialysis chronic kidney disease (T A Golper amp A M Sheridan Eds) Retrieved from UpToDate httpswww-uptodate-comproxywichitaeducontentstreatment-of-anemia-in-nondialysis-chronic-kidney-disease
bull Chan M Dall A T Fletcher K E Lu N amp Trivedi H (2007) Outcomes in patients with chronic kidney disease referred late to nephrologists a meta-analysis American Journal of Medicine 120(12) 1063-1070
bull Coresh J Selvin E amp Stevens L A (2007) Prevalence of chronic kidny disease in the United States JAMA 298(17) doi101001jama298172038
bull de Brito-Ashurst I Varagunam M Raftery M amp Yagoob M (2009) Bicarbonate supplementation slows progression of CKD and improves nutritional status Journal of American Society of Nephrology (20) 2075-2084
BIBLIOGRAPHY
bull Duncan L Heathcoat J Djurdjev O amp Levin A (2001) Screening for renal disease using serum creatinine who are we missing Nephrology Dialysis and Transplant 16(5) 1042-1046
bull Dunkler D Gao P Lee S F Heinz G Clase C M Tobe S Oberbauer R (2015 August 7) Risk prediction for early CKD in type 2 diabetes Retrieved from Clinical Journal of the American Society of Nephrology httpcjasnasnjournalsorgcontent1081371fullsid=61422554-a5f1-41ac-b696-dcd3b12bd268
bull Fatehi P amp Chi-yuan H (September 15 2016) Diagnostic approach to the patient with newly identified chronic kidney disease (G C Curhan amp A M Sheridan Eds) Retrieved May 7 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsdiagnostic-approach-to-the-patient-with-newly-identified-chronic-kidney-disease
bull Fink J e (2009) Chronic Kidney Disease as an Under-Recognized Threat to Patient Safety American journal of kidney diseases the official journal of the National Kidney Foundation 53(4) 681-688
bull Gaffo A L amp Saag K G (2008 Nov) Management of hyperuricemia and gout in CKD doihttpdxdoiorg101053jajkd200807035
bull Hebert L A amp Parikh S V (2014 June 18) Differential diagnosis and evaluation of glomerular disease (R J Glassock amp A Q Lam Eds) Retrieved May 7 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsdifferential-diagnosis-and-evaluation-of-glomerular-disease
bull Inker L Perrone R D Sterns R H amp Forman J P (2017 March 7) Assessment of kidney function Retrieved from UpToDate httpswww-uptodate-comproxywichitaeducontentsassessment-of-kidney-functionsource=search_resultampsearch=creatinineampselectedTitle=1~150
BIBLIOGRAPHY
bull James P A Ortiz E amp Et Al (2014) Evidence based guideline for the management of high blood pressure in adults (JNC) JAMA 311(5) 507-520
bull Kidney Disease Improving Global Outcomes (KDIGO) CKD Work Group (2013 January) KDIGO 2012 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease Retrieved from Kidney International Supplement httpwwwkidney-internationalorg
bull Kunz R Friedrich C Wolbers M amp Mann J F (2008) Meta-analysis effect of monotherapy and combination therapy with inhibitors of the renin angiotensin system on proteinuria in renal disease Annals of Internal Medicine 148(1) 30-48
bull Levey A Stevens L A Schmid C H Castro A F Feldman H I Kusek J W Coresh J (2009) A new equation to estimate glomerular filtration rate Annals of Internal Medicine 150(9) 604-612
bull Levin A Bakris G L Molitch M Smulders M M Williams L A amp Andress D L (2007 Jan) Prevalence of abnormal serum vitamin D PTH calcium and phosphorus in patients with chronic kidney disease results of the study to evaluate early kidney disease Kidney International 71(1) 31-38 Retrieved from PubMED
bull Mahajan A Simoni J Sheather S Broglio K Rajab M amp Wesson D (2010) Daily oral sodium bicarbonate preserves glomerular filtration rate by slowing its decline in early hypertensive nephropathy Kidney International (78_ 303-309
bull Mann J Schmieder R E amp McQueen M (2008) Renal outcomes with telmisartan ramipril or both in people at high vascular risk (the ONTARGET study) a multicentre randomised doubleblind ocntrolled trial Lancet 372(9638) 547-533
BIBLIOGRAPHY
bull Matovinović M S (2009) Pathophysiology and classification of kidney disease Retrieved from The Journal of the International Federation of Clinical Chemistry and Laboratory Medicine httpwwwifccorgifccfilesdocs20010902pdf
bull Moe S Drueke T Lameire N amp Eknoyan G (2007 Jan) Chronic kidney disease-mineral-bone disorder a new paradigmdoi101053jackd200610005
bull Murtagh F E Marsh J E Donohoe P Ekbal N J Sheerin N S amp Harris F E (2007 July) Dialysis or not A comparative survival study of patients over 75 years with chronic kidney disease stage 5 Retrieved from Nephrology Dialysis and Transplant 22(7) httpswwwncbinlmnihgovpubmed17412702
bull National Kidney Foundation (2002) KDOQI clinical practice guidelines for chronic kidney disease evaluation classification andstratification American Journal of Kidney Disease S1-S266
bull National Kidney Foundation (2014 November 5) Fact Sheets Retrieved from httpwwwkidneyorgnewsnewsroomfactsheetsFastFacts
bull Pal S (2012 June 2) Trends in chronic kidney disease Retrieved from US Pharmacist (37)6 httpswwwuspharmacistcomarticletrends-in-chronic-kidney-disease
bull Qunibi W amp Henrich W L (2017 Jan 19) Overview of chronic kidney disease-mineral and bone disorder (J Berns amp A M Sheridan Eds) Retrieved from UpToDate httpswww-uptodate-comoverview-of-chronic-kidney-disease-mineral-and-bone-disorder-ckd-mbd
bull Rosenberg M (2016 Feb 24) Overview of the management of chronic kidney disease in adults (G C Curhan amp A M Sheridan Eds) Retrieved from UpToDate UpToDate httpswww-uptodate-comproxywichitaeducontentsoverview-of-the-management-of-chronic-kidney-disease-in-adults
BIBLIOGRAPHY
bull Szczech L Stewart R C Hsu-Lin S DeLosky R J Astor B C Fox C H Vassalotti J A (2014) Primary care detection of chronic kidney disease in adults with type 2 diabetes The ADD-CKD Study (Awareness Detection and Drug Therapy in type 2 diabetes and chronic kidney disease PLOS doihttpsdoiorg101371journalpone0110535
bull USRDS (2016) Annual data report 2016 Epidemiology of kidney disease in the United States Retrieved from United States Renal Data System httpswwwusrdsorgadraspx
bull Vasudev B amp Vasudev M (2012) A model curriculum for residents rotating in nephrology MedEDPORTAL doihttpdoiorg1015766mep_2374-82658288
bull Wei L MacDonald T M Jennings C Sheng X amp Flynn R W (2013) Estimated GFR reporting is associated with decreased nonsteroidal anti-inflammatory drug prescribing and increased renal function Kidney International (84)1 174-178
chronic kidney disease in primary care
CKD as a Public Health Issue
Slide Number 3
Costs of CKD in 2013 dollarsUSRDS report
Steps to CKD Patient Care
Renal anatomy and physiology
Definition of Chronic Kidney Disease
CKD Risk Factors
Gaps in CKD Diagnosis
Slide Number 10
Steps to CKD Patient Care
creatinine
Glomerular filtration rate
Slide Number 14
Slide Number 15
Use These Equations Cautiously if at all in hellip
lab albumin creatinine ratio
The New CKD Categories
Steps to CKD Patient Care
Slide Number 20
Kidney Involvement in Systemic Diseases
Slide Number 22
Slide Number 23
DysmorphicRenal Hematuria
Slide Number 25
If you have albuminuria or hematuria-order the following labs
DIABETIC NEPHROPATHY 1 CAUSE OF CKDbull Clinical syndromebull Albuminuria gt30 mg 24 hrsbull Proteinuria gt500 mg24 hrsbull Hypertension developsbull Progressive increase in proteinuriabull Progressive decline in glomerular filtration rate
bull Chronic kidney disease should be attributed to diabetic nephropathies in most patients with diabetes if albuminuria and diabetic retinopathy are both present other causes of CKD should be entertained if diabetic retinopathy is absent (KDIGO 2007)
DIABETIC NEPHROPATHY MORTALITY
bull After 40 yrs of DM
bull 10 alive if proteinuria is present
bull 70 alive if proteinuria is absent
bull Heart Disease is 15 times higher risk in those with proteinuria
bull Proteinuria = death in this population
Dunkler et al 2015
GOALS OF CARE IN CKD GLUCOSE CONTROL
bull Target HbA1c ~70 (lt695 greatest chance of reducing albuminuria)bull Can be extended above 70 with comorbidities or limited life expectancy and
risk of hypoglycemiabull Risk of hypoglycemia increases as kidney function becomes impairedbull Declining kidney function may necessitate changes to diabetes medications and
bull Just having HTN can cause proteinuriabull Usually 1-2 gms of protein a daybull Treat them like a diabetic with ACEI or ARBS and tight blood
pressure controlbull JNC-8 goal lt14090 for ptrsquos with CKDbull National kidney foundation lt14090 if ckd and no proteinuria
lt13080 if proteinuria present
(James Ortiz amp Et Al 2014)
TREATING HYPERTENSIONPROTEINURIA ACEI ORARBbull Riskbenefit should be carefully assessed in the elderly and medically fragilebull Check labs after initiation
bull If less than 30 SCr increase continue and monitorbull If more than 30 SCr increase stop ACEi and evaluate for renal artery stenosis
bull Continue until contraindication arises no absolute eGFR cutoffbull Better proteinuria suppression with low Na diet and diureticsbull Avoid volume depletionbull Avoid ACEi and ARB in combination12
bull Risk of adverse events (impaired kidney function hyperkalemia)
(Kunz Friedrich Wolbers amp Mann 2008)(Mann Schmieder amp McQueen 2008)
bull In adults gt50 yrs statin when eGFR ge 60 mlmin173m2 statin or statinezetimibe combination when eGFR lt 60 mlmin173m2
bull In adults lt 50 yrs statin if history of known CAD MI DM strokebull Aspirin is indicated for secondary but not primary prevention
Kidney Disease Improving Global Outcomes (KDIGO) CKD Work Group Kidney Int Suppls 201331-150
STATINS-RENOPROTECTIVECONTROVERSY
bull HMG-CoA reductase inhibitors (statins) in high doses can cause proteinuria
bull Possibly associated with less inflammation endothelial dysfunction and scarring in the kidney because they also block inflammatory cytokines
bull Use statins for CV disease not to treat proteinuria
(Afzali and Goldsmith 2016)
MEDICINE CAUTION
bull Hold metformin when gfr lt35 mlmin
bull GFR lt50 mlmin should alert to check all doses of meds
bull No bisphosphanates lt35 mlmin
bull No NSAIDScox 2 inhibitors lt60 mlmin
bull Atenolol ndashrenal excretion
bull BACTRIM A lot of AKI
MEDICINE CAUTION
bull Lovenox-use subcut heparinbull Apixibanbull Dabigatranbull Rivaroxibanbull Lithiumbull GABAPENTIN (ckd 4 max 300mg qd ckd 5 max 300mg qod)
STEPS TO CKD PATIENT CARE
1 CKD definition and risks2 Assess GFR albuminuria3 Determine etiology4 Assess for evidence of progression5 Assess for associated complications6 Discuss dialysistransplantation
CKD-CVD-DIABETES LINK CKD IS A DISEASE MULTIPLIER
National kidney foundation 2014
KDIGO 2017
CKD-MINERAL BONE DISORDERS
bull As kidneys fail they
bull Stop activating calcitriol (the active form of Vit D)mdashcausing calcium imbalance
bull Do not remove phosphorus from bloodmdashleading to phosphorus retention
bull The extra phosphorus pulls calcium out of bones causing them to weaken
bull High phosphorus stimulates PTH release
bull These changes (plus others) cause the start of secondary hyperparathyroidism
bull Labs
bull eGFR
bull Calcium
bull Phos
bull Vit D
bull iPTH
(Qunibi amp Henrich 2017)
PREVALENCE OF ABNORMALITIES OF MINERAL METABOLISM PTH IN CKD
bull Progression of disease ndash declining eGFR increasing proteinuria
bull Degree of proteinuria nephrotic syndrome gt 05-10 gd on ACEi or ARB therapy
bull Etiology of CKD not certain
bull Need help with disease management
bull Indications for kidney biopsy
Rosenberg 2016
WHEN TO REFER
STEPS TO CKD PATIENT CARE
1 CKD definition and risks2 Assess GFR albuminuria3 Determine etiology4 Assess for evidence of progression5 Assess for associated complications6 Discuss dialysistransplantation
KIDNEY TRANSPLANTATION
bull Treatment of choice for ESRDbull Improves quality of lifebull Waiting list time varies-3-5 yearsbull 3 year survival rate after transplantation is 83-94bull Increased risk of cancer
STARTING DIALYSIS IN THE ELDERLYhellipOR NOT
bull Among patients gt 75 yrs with stage 5 CKD who chose to NOT start dialysisbull Overall more likely to die over next 1-2 years bull But if they had ischemic heart disease or other significant comorbidity NO
DIFFERENCE in survival
bull Active disease management and supportive care may be appropriate without starting dialysis in the ill elderly
bull Palliative care does not mean ldquono carerdquo
bull Must have end-of-life discussions
(Murtagh et al 2007)
CKD MANAGEMENTbull Diagnose cause and treat underlying conditionbull Stage per guidelinesbull Slow progression of kidney disease (ACE inhibitors)bull Monitor for complicationsmdashvolume overload hyperkalemia metabolic acidosis
hyperphosphatemia anorexia fatigue htn bone diseasebull Labs cmp cbc phos Vit D 25OH iPTH urine microscopy uric acid urine
proteincr ratio-frequency based off heat map Get sono at least oncebull Vaccinate influenza hep B pneumococcalbull Eval ASCVD risk-likely needs statinbull Possible dexa (donrsquot give bisphosphonates if GFRlt35 let specialist manage)bull Refer to nephrology when eGFR is lt30 (sometimes if higher risk-refer earlier)
CASE 1
bull 55 year old man with past medical history of headaches presents to your office for his first time visit to a PCP in over 30 years
bull He has no past history of being admitted to the hospital and he does not take any OTC medsNSAIDsherbal meds He has no history of ETOH abuse smoking or drug use
bull Vitals BP 180100 mmHg pulse 80 R 18
bull Exam No JVD S1S2 regular PMI shifted to the left no gallop no abdominal bruit pulses bilaterally equal and regular no leg edema
bull What would you order
bull EKG cbc cmp ua urine proteincr ratio lipid
LAB RESULTS
bull Labs reveal a creatinine of 22 mgdL eGFR 33 Urine shows no blood or casts Urineprotein ratio shows 1 gm protein24 hrs EKG shows LVH
bull Next step in workupbull Renal ultrasound 1st then SPEP UPEP with immunofixation serum free light chains
bull Additional labs neg Renal ultrasound shows that both kidneys are slightly reduced in size and are mildly echogenic with no mass or hydronephrosis
bull What is your diagnosis
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileMain_complications_of_persistent_high_blood_pressurepngCreative Commons License associated httpcreativecommonsorglicensesby-sa30
bull 3 months Howevermdashwe have evidence of structural abnormalities Could potentially stage at G3b A3 (red on the heat map)
bull Goal blood pressure
bull JNC 8 14090 NKF 13080
bull Additional lab needed for progression monitoring
bull Cbc renal panel phos Vit D iPTH uric acid urine micro (we already have the renal sono and urine proteincr ratio and lipid)
Selective renal angiography (left lower renal artery) after successful percutaneous balloon dilatation of the stenotic lesionFibromuscular dysplasia in an accessory renal artery causing renovascular hypertension
Secondary Hypertension
Images retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileRenal_FMD2jpg and httpcommonswikimediaorgwikiFileRenal_FMDjpgCreative Commons License associated httpcreativecommonsorglicensesby20deeden (both images)
CASE 2bull OS is a 64year old Hispanic female in for DM check She has had DM for 15+ years and is currently
taking metformin 1000mg bid Lisinopril 10mg a day atorvastatin 40mg a day Labs today showed the following
bull Hgba1c 86 cmp eGFR 50 lipid WNL proteincr ratio 650mg These results are similar to her last visit
bull Upon further hx-you find that she had a recent eye exam and has mild nonproliferaive retinopathy She does not have neuropathy or other ss
bull What further workup do you need
bull Renal sonogram urine micro iPTH vit D (25 OH) phos uric acid
bull Dx stage
bull G3a A3
bull What further treatment do you need
bull Improve glycemic control Increase Lisinopril to 20mg with a goal of 40mg Avoid NSAIDs or other nephrotoxic agents make sure meds are renally dosed monitor 3xyear nephro referral
MANAGEMENT OF CKD IN DIABETESeGFR Recommended
All patients
Yearly measurement of creatinine urinary albumin excretion potassium
45-60 Referral to a nephrologist if possibility for nondiabetickidney disease existsConsider dose adjustment of medicationsMonitor eGFR every 6 monthsMonitor electrolytes bicarbonate hemoglobin calcium phosphorus parathyroid hormone at least yearly
Assure vitamin D sufficiencyConsider bone density testingReferral for dietary counselling
American Diabetes Association Standards of Medical Care in Diabetes Microvascular complications and foot care Diabetes Care 2017 40 (Suppl 1) S88-S98
CASE 3
bull 19 year old African American woman presents to your clinic with complaints of fatigue joint pains a new rash on her face oral ulcer
bull On exam BP 15080 P 88 Afebrile 96 O2 sats on RAbull GEN No respiratory distress at restbull HEENT painless oral ulcer flat rash over malar eminences sparing the nasolabial fold pallor +bull Lungs CTAbull CVS S1S2 regularbull Abdomen soft NTbull Ext left elbow joint and bilateral wrist joints are swollen and tender
bull What would you orderbull CBC CMP ua urine microscopy (microalbumin or urine proteincr ratio) ANA esr RF anti-ccp uric acid TSH
CASE 3
bull Working dx fatigue oral ulcer joint pain
bull Basic Labs Na 135 K 55 Bicarb 18 BUN 50 Cr 35 eGFR 22 Ca 90 ANA + titer 1640
bull UA 3+ blood 3+ protein RBC casts +
bull Given these results what is the most likely diagnosis
bull What would you do
SYSTEMIC LUPUS ERYTHEMATOSUS (SLE)
bull SLE multisystemic disease Etiology unknown
bull Production of autoantibodies and immune complexes formation
bull There is renal involvement in the great majority of patients with SLE at some time of the evolution 66-90
SLE ndash LUPUS NEPHRITIS
bull Race SLE is more commonsevere in African americans than Caucasiansbull
bull Gender female-to-male ratio of 91
bull Age Most patients develop lupus nephritis early in their disease course SLE is more common among women in the third decade of life and lupus nephritis occurs in patients aged 20-40 years
bull Kidney Biopsy For staging lupus nephritis (Class 1-5)
CASE 5bull A 80 year old man who has not seen a PCP in many years
presents to your clinic for weakness for the past few months On further questioning he tells you that his bones also have been hurting lately and he has developed leg swelling in the past month or so
bull On exam bull BP 16090 P 88 Afebrilebull GEN Thin built manbull HEENT pallor presentbull Lungs clearbull CVS S1S2 regular no rub or gallopbull Abdomen soft NTbull Ext 2 + edema
CASE 5
bull Differentials
bull CHF MI Cancer arthritis
bull Labs
bull CBC CMP urine microscopy urine proteincr ratio ESR TSH EKG BNP pa and lat CXR
bull LABS Urine dipstick negative for protein or blood
bull Basic chem bull Na 136 (135-145) K 51 (35-55) Chloride 108 (96-106) Bicarb 25
Given this presentation and the labs (low anion gap and elevated calcium anemia kidney failure) what will you think of What will you order next
Serum and urine protein electrophoresis
Intratubular refractile casts with surrounding syncytial giant cell reaction with chronic tubulointerstitial nephritis and fibrosis characteristic of myeloma cast nephropathy
Kidney Biopsy
CASE STUDYbull A 35 year old African American woman was seen in the clinic for
chronic cough and dyspnea on exertion She gave history of vague symptoms of fatigue and weight loss of 20 Ibs over the last six months
bull List some differentialsbull TB sarcoid lupus thyroid problems PEbull What would you orderbull PPD cbc cmp UA TSH ANA pa and lat cxr
bull Her labs were significant for mildly elevated calcium level and a creatinine of 20 mgdL eGFR 37
bull She had 750 mg of proteinuriaday
bull PPD neg ANA neg TSH and other labs WNL
bull Assuming this is present more than 3 monthshelliphellipwhat is her ckd stage
bull G3b A3
bull What do we still need
CT scan of chest
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileAnterior_mediastinal_mass_thymomajpgCreative Commons License associated httpcreativecommonsorglicensesby20deeden
CXR ndash HILAR LYMPHADENOPATHY
WHATS NEEDED NEXT
bull Biopsy of hilar lymphadenopathy or renal biopsy
bull DX sarcoidosis
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileSarcoidosis_signs_and_symptomsjpgThis work is in the public domain in the United States because it is a work of the United States Federal Government under the terms of Title 17 Chapter 1 Section 105 of the US Code
NEWLY DX CKD
bull 1) urinalysis microscopy ultrasound proteincr ratio
bull If obstruction-treat
bull No obstruction
bull Hx critical (consider myeloma if high risk)
bull glomerular bleeding or albumin in urine
bull Yes workup for glomerular causes (ANArf hep B C upep spep ANCA complement C3 C4)
bull No sterile pyruria-consider interstitial nephritis
bull High risk renovascular disease Evaluate renovascular disease
Additional Online Resources for CKD LearningbullNational Kidney Foundation wwwkidneyorgbullUnited States Renal Data Service wwwusrdsorgbullCDCrsquos CKD Surveillance Project
httpnccdcdcgovckdbullNational Kidney Disease Education Program
(NKDEP) httpnkdepnihgov
BIBLIOGRAPHY
bull Afzali B amp Goldsmith D J (2016 June 29) Statins and chronic kidney disease (G C Curhan amp A M Sheridan Eds) Retrieved 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsstatins-and-chronic-kidney-disease
bull American Diabetes Association Standards of Medical Care in Diabetes (2017) Microvascular complications and foot care Diabetes Care 2017 (40) S88-S98
bull American Diabetes Association Standards of Medical Care in Diabetes (2017) Microvascular complications and foot care Diabetes Care 40 (suppl 1) S88-S98
bull Berns J S (2017 Mar 22) Treatment of anemia in nondialysis chronic kidney disease (T A Golper amp A M Sheridan Eds) Retrieved from UpToDate httpswww-uptodate-comproxywichitaeducontentstreatment-of-anemia-in-nondialysis-chronic-kidney-disease
bull Chan M Dall A T Fletcher K E Lu N amp Trivedi H (2007) Outcomes in patients with chronic kidney disease referred late to nephrologists a meta-analysis American Journal of Medicine 120(12) 1063-1070
bull Coresh J Selvin E amp Stevens L A (2007) Prevalence of chronic kidny disease in the United States JAMA 298(17) doi101001jama298172038
bull de Brito-Ashurst I Varagunam M Raftery M amp Yagoob M (2009) Bicarbonate supplementation slows progression of CKD and improves nutritional status Journal of American Society of Nephrology (20) 2075-2084
BIBLIOGRAPHY
bull Duncan L Heathcoat J Djurdjev O amp Levin A (2001) Screening for renal disease using serum creatinine who are we missing Nephrology Dialysis and Transplant 16(5) 1042-1046
bull Dunkler D Gao P Lee S F Heinz G Clase C M Tobe S Oberbauer R (2015 August 7) Risk prediction for early CKD in type 2 diabetes Retrieved from Clinical Journal of the American Society of Nephrology httpcjasnasnjournalsorgcontent1081371fullsid=61422554-a5f1-41ac-b696-dcd3b12bd268
bull Fatehi P amp Chi-yuan H (September 15 2016) Diagnostic approach to the patient with newly identified chronic kidney disease (G C Curhan amp A M Sheridan Eds) Retrieved May 7 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsdiagnostic-approach-to-the-patient-with-newly-identified-chronic-kidney-disease
bull Fink J e (2009) Chronic Kidney Disease as an Under-Recognized Threat to Patient Safety American journal of kidney diseases the official journal of the National Kidney Foundation 53(4) 681-688
bull Gaffo A L amp Saag K G (2008 Nov) Management of hyperuricemia and gout in CKD doihttpdxdoiorg101053jajkd200807035
bull Hebert L A amp Parikh S V (2014 June 18) Differential diagnosis and evaluation of glomerular disease (R J Glassock amp A Q Lam Eds) Retrieved May 7 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsdifferential-diagnosis-and-evaluation-of-glomerular-disease
bull Inker L Perrone R D Sterns R H amp Forman J P (2017 March 7) Assessment of kidney function Retrieved from UpToDate httpswww-uptodate-comproxywichitaeducontentsassessment-of-kidney-functionsource=search_resultampsearch=creatinineampselectedTitle=1~150
BIBLIOGRAPHY
bull James P A Ortiz E amp Et Al (2014) Evidence based guideline for the management of high blood pressure in adults (JNC) JAMA 311(5) 507-520
bull Kidney Disease Improving Global Outcomes (KDIGO) CKD Work Group (2013 January) KDIGO 2012 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease Retrieved from Kidney International Supplement httpwwwkidney-internationalorg
bull Kunz R Friedrich C Wolbers M amp Mann J F (2008) Meta-analysis effect of monotherapy and combination therapy with inhibitors of the renin angiotensin system on proteinuria in renal disease Annals of Internal Medicine 148(1) 30-48
bull Levey A Stevens L A Schmid C H Castro A F Feldman H I Kusek J W Coresh J (2009) A new equation to estimate glomerular filtration rate Annals of Internal Medicine 150(9) 604-612
bull Levin A Bakris G L Molitch M Smulders M M Williams L A amp Andress D L (2007 Jan) Prevalence of abnormal serum vitamin D PTH calcium and phosphorus in patients with chronic kidney disease results of the study to evaluate early kidney disease Kidney International 71(1) 31-38 Retrieved from PubMED
bull Mahajan A Simoni J Sheather S Broglio K Rajab M amp Wesson D (2010) Daily oral sodium bicarbonate preserves glomerular filtration rate by slowing its decline in early hypertensive nephropathy Kidney International (78_ 303-309
bull Mann J Schmieder R E amp McQueen M (2008) Renal outcomes with telmisartan ramipril or both in people at high vascular risk (the ONTARGET study) a multicentre randomised doubleblind ocntrolled trial Lancet 372(9638) 547-533
BIBLIOGRAPHY
bull Matovinović M S (2009) Pathophysiology and classification of kidney disease Retrieved from The Journal of the International Federation of Clinical Chemistry and Laboratory Medicine httpwwwifccorgifccfilesdocs20010902pdf
bull Moe S Drueke T Lameire N amp Eknoyan G (2007 Jan) Chronic kidney disease-mineral-bone disorder a new paradigmdoi101053jackd200610005
bull Murtagh F E Marsh J E Donohoe P Ekbal N J Sheerin N S amp Harris F E (2007 July) Dialysis or not A comparative survival study of patients over 75 years with chronic kidney disease stage 5 Retrieved from Nephrology Dialysis and Transplant 22(7) httpswwwncbinlmnihgovpubmed17412702
bull National Kidney Foundation (2002) KDOQI clinical practice guidelines for chronic kidney disease evaluation classification andstratification American Journal of Kidney Disease S1-S266
bull National Kidney Foundation (2014 November 5) Fact Sheets Retrieved from httpwwwkidneyorgnewsnewsroomfactsheetsFastFacts
bull Pal S (2012 June 2) Trends in chronic kidney disease Retrieved from US Pharmacist (37)6 httpswwwuspharmacistcomarticletrends-in-chronic-kidney-disease
bull Qunibi W amp Henrich W L (2017 Jan 19) Overview of chronic kidney disease-mineral and bone disorder (J Berns amp A M Sheridan Eds) Retrieved from UpToDate httpswww-uptodate-comoverview-of-chronic-kidney-disease-mineral-and-bone-disorder-ckd-mbd
bull Rosenberg M (2016 Feb 24) Overview of the management of chronic kidney disease in adults (G C Curhan amp A M Sheridan Eds) Retrieved from UpToDate UpToDate httpswww-uptodate-comproxywichitaeducontentsoverview-of-the-management-of-chronic-kidney-disease-in-adults
BIBLIOGRAPHY
bull Szczech L Stewart R C Hsu-Lin S DeLosky R J Astor B C Fox C H Vassalotti J A (2014) Primary care detection of chronic kidney disease in adults with type 2 diabetes The ADD-CKD Study (Awareness Detection and Drug Therapy in type 2 diabetes and chronic kidney disease PLOS doihttpsdoiorg101371journalpone0110535
bull USRDS (2016) Annual data report 2016 Epidemiology of kidney disease in the United States Retrieved from United States Renal Data System httpswwwusrdsorgadraspx
bull Vasudev B amp Vasudev M (2012) A model curriculum for residents rotating in nephrology MedEDPORTAL doihttpdoiorg1015766mep_2374-82658288
bull Wei L MacDonald T M Jennings C Sheng X amp Flynn R W (2013) Estimated GFR reporting is associated with decreased nonsteroidal anti-inflammatory drug prescribing and increased renal function Kidney International (84)1 174-178
chronic kidney disease in primary care
CKD as a Public Health Issue
Slide Number 3
Costs of CKD in 2013 dollarsUSRDS report
Steps to CKD Patient Care
Renal anatomy and physiology
Definition of Chronic Kidney Disease
CKD Risk Factors
Gaps in CKD Diagnosis
Slide Number 10
Steps to CKD Patient Care
creatinine
Glomerular filtration rate
Slide Number 14
Slide Number 15
Use These Equations Cautiously if at all in hellip
lab albumin creatinine ratio
The New CKD Categories
Steps to CKD Patient Care
Slide Number 20
Kidney Involvement in Systemic Diseases
Slide Number 22
Slide Number 23
DysmorphicRenal Hematuria
Slide Number 25
If you have albuminuria or hematuria-order the following labs
DIABETIC NEPHROPATHY 1 CAUSE OF CKDbull Clinical syndromebull Albuminuria gt30 mg 24 hrsbull Proteinuria gt500 mg24 hrsbull Hypertension developsbull Progressive increase in proteinuriabull Progressive decline in glomerular filtration rate
bull Chronic kidney disease should be attributed to diabetic nephropathies in most patients with diabetes if albuminuria and diabetic retinopathy are both present other causes of CKD should be entertained if diabetic retinopathy is absent (KDIGO 2007)
DIABETIC NEPHROPATHY MORTALITY
bull After 40 yrs of DM
bull 10 alive if proteinuria is present
bull 70 alive if proteinuria is absent
bull Heart Disease is 15 times higher risk in those with proteinuria
bull Proteinuria = death in this population
Dunkler et al 2015
GOALS OF CARE IN CKD GLUCOSE CONTROL
bull Target HbA1c ~70 (lt695 greatest chance of reducing albuminuria)bull Can be extended above 70 with comorbidities or limited life expectancy and
risk of hypoglycemiabull Risk of hypoglycemia increases as kidney function becomes impairedbull Declining kidney function may necessitate changes to diabetes medications and
bull Just having HTN can cause proteinuriabull Usually 1-2 gms of protein a daybull Treat them like a diabetic with ACEI or ARBS and tight blood
pressure controlbull JNC-8 goal lt14090 for ptrsquos with CKDbull National kidney foundation lt14090 if ckd and no proteinuria
lt13080 if proteinuria present
(James Ortiz amp Et Al 2014)
TREATING HYPERTENSIONPROTEINURIA ACEI ORARBbull Riskbenefit should be carefully assessed in the elderly and medically fragilebull Check labs after initiation
bull If less than 30 SCr increase continue and monitorbull If more than 30 SCr increase stop ACEi and evaluate for renal artery stenosis
bull Continue until contraindication arises no absolute eGFR cutoffbull Better proteinuria suppression with low Na diet and diureticsbull Avoid volume depletionbull Avoid ACEi and ARB in combination12
bull Risk of adverse events (impaired kidney function hyperkalemia)
(Kunz Friedrich Wolbers amp Mann 2008)(Mann Schmieder amp McQueen 2008)
bull In adults gt50 yrs statin when eGFR ge 60 mlmin173m2 statin or statinezetimibe combination when eGFR lt 60 mlmin173m2
bull In adults lt 50 yrs statin if history of known CAD MI DM strokebull Aspirin is indicated for secondary but not primary prevention
Kidney Disease Improving Global Outcomes (KDIGO) CKD Work Group Kidney Int Suppls 201331-150
STATINS-RENOPROTECTIVECONTROVERSY
bull HMG-CoA reductase inhibitors (statins) in high doses can cause proteinuria
bull Possibly associated with less inflammation endothelial dysfunction and scarring in the kidney because they also block inflammatory cytokines
bull Use statins for CV disease not to treat proteinuria
(Afzali and Goldsmith 2016)
MEDICINE CAUTION
bull Hold metformin when gfr lt35 mlmin
bull GFR lt50 mlmin should alert to check all doses of meds
bull No bisphosphanates lt35 mlmin
bull No NSAIDScox 2 inhibitors lt60 mlmin
bull Atenolol ndashrenal excretion
bull BACTRIM A lot of AKI
MEDICINE CAUTION
bull Lovenox-use subcut heparinbull Apixibanbull Dabigatranbull Rivaroxibanbull Lithiumbull GABAPENTIN (ckd 4 max 300mg qd ckd 5 max 300mg qod)
STEPS TO CKD PATIENT CARE
1 CKD definition and risks2 Assess GFR albuminuria3 Determine etiology4 Assess for evidence of progression5 Assess for associated complications6 Discuss dialysistransplantation
CKD-CVD-DIABETES LINK CKD IS A DISEASE MULTIPLIER
National kidney foundation 2014
KDIGO 2017
CKD-MINERAL BONE DISORDERS
bull As kidneys fail they
bull Stop activating calcitriol (the active form of Vit D)mdashcausing calcium imbalance
bull Do not remove phosphorus from bloodmdashleading to phosphorus retention
bull The extra phosphorus pulls calcium out of bones causing them to weaken
bull High phosphorus stimulates PTH release
bull These changes (plus others) cause the start of secondary hyperparathyroidism
bull Labs
bull eGFR
bull Calcium
bull Phos
bull Vit D
bull iPTH
(Qunibi amp Henrich 2017)
PREVALENCE OF ABNORMALITIES OF MINERAL METABOLISM PTH IN CKD
bull Progression of disease ndash declining eGFR increasing proteinuria
bull Degree of proteinuria nephrotic syndrome gt 05-10 gd on ACEi or ARB therapy
bull Etiology of CKD not certain
bull Need help with disease management
bull Indications for kidney biopsy
Rosenberg 2016
WHEN TO REFER
STEPS TO CKD PATIENT CARE
1 CKD definition and risks2 Assess GFR albuminuria3 Determine etiology4 Assess for evidence of progression5 Assess for associated complications6 Discuss dialysistransplantation
KIDNEY TRANSPLANTATION
bull Treatment of choice for ESRDbull Improves quality of lifebull Waiting list time varies-3-5 yearsbull 3 year survival rate after transplantation is 83-94bull Increased risk of cancer
STARTING DIALYSIS IN THE ELDERLYhellipOR NOT
bull Among patients gt 75 yrs with stage 5 CKD who chose to NOT start dialysisbull Overall more likely to die over next 1-2 years bull But if they had ischemic heart disease or other significant comorbidity NO
DIFFERENCE in survival
bull Active disease management and supportive care may be appropriate without starting dialysis in the ill elderly
bull Palliative care does not mean ldquono carerdquo
bull Must have end-of-life discussions
(Murtagh et al 2007)
CKD MANAGEMENTbull Diagnose cause and treat underlying conditionbull Stage per guidelinesbull Slow progression of kidney disease (ACE inhibitors)bull Monitor for complicationsmdashvolume overload hyperkalemia metabolic acidosis
hyperphosphatemia anorexia fatigue htn bone diseasebull Labs cmp cbc phos Vit D 25OH iPTH urine microscopy uric acid urine
proteincr ratio-frequency based off heat map Get sono at least oncebull Vaccinate influenza hep B pneumococcalbull Eval ASCVD risk-likely needs statinbull Possible dexa (donrsquot give bisphosphonates if GFRlt35 let specialist manage)bull Refer to nephrology when eGFR is lt30 (sometimes if higher risk-refer earlier)
CASE 1
bull 55 year old man with past medical history of headaches presents to your office for his first time visit to a PCP in over 30 years
bull He has no past history of being admitted to the hospital and he does not take any OTC medsNSAIDsherbal meds He has no history of ETOH abuse smoking or drug use
bull Vitals BP 180100 mmHg pulse 80 R 18
bull Exam No JVD S1S2 regular PMI shifted to the left no gallop no abdominal bruit pulses bilaterally equal and regular no leg edema
bull What would you order
bull EKG cbc cmp ua urine proteincr ratio lipid
LAB RESULTS
bull Labs reveal a creatinine of 22 mgdL eGFR 33 Urine shows no blood or casts Urineprotein ratio shows 1 gm protein24 hrs EKG shows LVH
bull Next step in workupbull Renal ultrasound 1st then SPEP UPEP with immunofixation serum free light chains
bull Additional labs neg Renal ultrasound shows that both kidneys are slightly reduced in size and are mildly echogenic with no mass or hydronephrosis
bull What is your diagnosis
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileMain_complications_of_persistent_high_blood_pressurepngCreative Commons License associated httpcreativecommonsorglicensesby-sa30
bull 3 months Howevermdashwe have evidence of structural abnormalities Could potentially stage at G3b A3 (red on the heat map)
bull Goal blood pressure
bull JNC 8 14090 NKF 13080
bull Additional lab needed for progression monitoring
bull Cbc renal panel phos Vit D iPTH uric acid urine micro (we already have the renal sono and urine proteincr ratio and lipid)
Selective renal angiography (left lower renal artery) after successful percutaneous balloon dilatation of the stenotic lesionFibromuscular dysplasia in an accessory renal artery causing renovascular hypertension
Secondary Hypertension
Images retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileRenal_FMD2jpg and httpcommonswikimediaorgwikiFileRenal_FMDjpgCreative Commons License associated httpcreativecommonsorglicensesby20deeden (both images)
CASE 2bull OS is a 64year old Hispanic female in for DM check She has had DM for 15+ years and is currently
taking metformin 1000mg bid Lisinopril 10mg a day atorvastatin 40mg a day Labs today showed the following
bull Hgba1c 86 cmp eGFR 50 lipid WNL proteincr ratio 650mg These results are similar to her last visit
bull Upon further hx-you find that she had a recent eye exam and has mild nonproliferaive retinopathy She does not have neuropathy or other ss
bull What further workup do you need
bull Renal sonogram urine micro iPTH vit D (25 OH) phos uric acid
bull Dx stage
bull G3a A3
bull What further treatment do you need
bull Improve glycemic control Increase Lisinopril to 20mg with a goal of 40mg Avoid NSAIDs or other nephrotoxic agents make sure meds are renally dosed monitor 3xyear nephro referral
MANAGEMENT OF CKD IN DIABETESeGFR Recommended
All patients
Yearly measurement of creatinine urinary albumin excretion potassium
45-60 Referral to a nephrologist if possibility for nondiabetickidney disease existsConsider dose adjustment of medicationsMonitor eGFR every 6 monthsMonitor electrolytes bicarbonate hemoglobin calcium phosphorus parathyroid hormone at least yearly
Assure vitamin D sufficiencyConsider bone density testingReferral for dietary counselling
American Diabetes Association Standards of Medical Care in Diabetes Microvascular complications and foot care Diabetes Care 2017 40 (Suppl 1) S88-S98
CASE 3
bull 19 year old African American woman presents to your clinic with complaints of fatigue joint pains a new rash on her face oral ulcer
bull On exam BP 15080 P 88 Afebrile 96 O2 sats on RAbull GEN No respiratory distress at restbull HEENT painless oral ulcer flat rash over malar eminences sparing the nasolabial fold pallor +bull Lungs CTAbull CVS S1S2 regularbull Abdomen soft NTbull Ext left elbow joint and bilateral wrist joints are swollen and tender
bull What would you orderbull CBC CMP ua urine microscopy (microalbumin or urine proteincr ratio) ANA esr RF anti-ccp uric acid TSH
CASE 3
bull Working dx fatigue oral ulcer joint pain
bull Basic Labs Na 135 K 55 Bicarb 18 BUN 50 Cr 35 eGFR 22 Ca 90 ANA + titer 1640
bull UA 3+ blood 3+ protein RBC casts +
bull Given these results what is the most likely diagnosis
bull What would you do
SYSTEMIC LUPUS ERYTHEMATOSUS (SLE)
bull SLE multisystemic disease Etiology unknown
bull Production of autoantibodies and immune complexes formation
bull There is renal involvement in the great majority of patients with SLE at some time of the evolution 66-90
SLE ndash LUPUS NEPHRITIS
bull Race SLE is more commonsevere in African americans than Caucasiansbull
bull Gender female-to-male ratio of 91
bull Age Most patients develop lupus nephritis early in their disease course SLE is more common among women in the third decade of life and lupus nephritis occurs in patients aged 20-40 years
bull Kidney Biopsy For staging lupus nephritis (Class 1-5)
CASE 5bull A 80 year old man who has not seen a PCP in many years
presents to your clinic for weakness for the past few months On further questioning he tells you that his bones also have been hurting lately and he has developed leg swelling in the past month or so
bull On exam bull BP 16090 P 88 Afebrilebull GEN Thin built manbull HEENT pallor presentbull Lungs clearbull CVS S1S2 regular no rub or gallopbull Abdomen soft NTbull Ext 2 + edema
CASE 5
bull Differentials
bull CHF MI Cancer arthritis
bull Labs
bull CBC CMP urine microscopy urine proteincr ratio ESR TSH EKG BNP pa and lat CXR
bull LABS Urine dipstick negative for protein or blood
bull Basic chem bull Na 136 (135-145) K 51 (35-55) Chloride 108 (96-106) Bicarb 25
Given this presentation and the labs (low anion gap and elevated calcium anemia kidney failure) what will you think of What will you order next
Serum and urine protein electrophoresis
Intratubular refractile casts with surrounding syncytial giant cell reaction with chronic tubulointerstitial nephritis and fibrosis characteristic of myeloma cast nephropathy
Kidney Biopsy
CASE STUDYbull A 35 year old African American woman was seen in the clinic for
chronic cough and dyspnea on exertion She gave history of vague symptoms of fatigue and weight loss of 20 Ibs over the last six months
bull List some differentialsbull TB sarcoid lupus thyroid problems PEbull What would you orderbull PPD cbc cmp UA TSH ANA pa and lat cxr
bull Her labs were significant for mildly elevated calcium level and a creatinine of 20 mgdL eGFR 37
bull She had 750 mg of proteinuriaday
bull PPD neg ANA neg TSH and other labs WNL
bull Assuming this is present more than 3 monthshelliphellipwhat is her ckd stage
bull G3b A3
bull What do we still need
CT scan of chest
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileAnterior_mediastinal_mass_thymomajpgCreative Commons License associated httpcreativecommonsorglicensesby20deeden
CXR ndash HILAR LYMPHADENOPATHY
WHATS NEEDED NEXT
bull Biopsy of hilar lymphadenopathy or renal biopsy
bull DX sarcoidosis
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileSarcoidosis_signs_and_symptomsjpgThis work is in the public domain in the United States because it is a work of the United States Federal Government under the terms of Title 17 Chapter 1 Section 105 of the US Code
NEWLY DX CKD
bull 1) urinalysis microscopy ultrasound proteincr ratio
bull If obstruction-treat
bull No obstruction
bull Hx critical (consider myeloma if high risk)
bull glomerular bleeding or albumin in urine
bull Yes workup for glomerular causes (ANArf hep B C upep spep ANCA complement C3 C4)
bull No sterile pyruria-consider interstitial nephritis
bull High risk renovascular disease Evaluate renovascular disease
Additional Online Resources for CKD LearningbullNational Kidney Foundation wwwkidneyorgbullUnited States Renal Data Service wwwusrdsorgbullCDCrsquos CKD Surveillance Project
httpnccdcdcgovckdbullNational Kidney Disease Education Program
(NKDEP) httpnkdepnihgov
BIBLIOGRAPHY
bull Afzali B amp Goldsmith D J (2016 June 29) Statins and chronic kidney disease (G C Curhan amp A M Sheridan Eds) Retrieved 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsstatins-and-chronic-kidney-disease
bull American Diabetes Association Standards of Medical Care in Diabetes (2017) Microvascular complications and foot care Diabetes Care 2017 (40) S88-S98
bull American Diabetes Association Standards of Medical Care in Diabetes (2017) Microvascular complications and foot care Diabetes Care 40 (suppl 1) S88-S98
bull Berns J S (2017 Mar 22) Treatment of anemia in nondialysis chronic kidney disease (T A Golper amp A M Sheridan Eds) Retrieved from UpToDate httpswww-uptodate-comproxywichitaeducontentstreatment-of-anemia-in-nondialysis-chronic-kidney-disease
bull Chan M Dall A T Fletcher K E Lu N amp Trivedi H (2007) Outcomes in patients with chronic kidney disease referred late to nephrologists a meta-analysis American Journal of Medicine 120(12) 1063-1070
bull Coresh J Selvin E amp Stevens L A (2007) Prevalence of chronic kidny disease in the United States JAMA 298(17) doi101001jama298172038
bull de Brito-Ashurst I Varagunam M Raftery M amp Yagoob M (2009) Bicarbonate supplementation slows progression of CKD and improves nutritional status Journal of American Society of Nephrology (20) 2075-2084
BIBLIOGRAPHY
bull Duncan L Heathcoat J Djurdjev O amp Levin A (2001) Screening for renal disease using serum creatinine who are we missing Nephrology Dialysis and Transplant 16(5) 1042-1046
bull Dunkler D Gao P Lee S F Heinz G Clase C M Tobe S Oberbauer R (2015 August 7) Risk prediction for early CKD in type 2 diabetes Retrieved from Clinical Journal of the American Society of Nephrology httpcjasnasnjournalsorgcontent1081371fullsid=61422554-a5f1-41ac-b696-dcd3b12bd268
bull Fatehi P amp Chi-yuan H (September 15 2016) Diagnostic approach to the patient with newly identified chronic kidney disease (G C Curhan amp A M Sheridan Eds) Retrieved May 7 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsdiagnostic-approach-to-the-patient-with-newly-identified-chronic-kidney-disease
bull Fink J e (2009) Chronic Kidney Disease as an Under-Recognized Threat to Patient Safety American journal of kidney diseases the official journal of the National Kidney Foundation 53(4) 681-688
bull Gaffo A L amp Saag K G (2008 Nov) Management of hyperuricemia and gout in CKD doihttpdxdoiorg101053jajkd200807035
bull Hebert L A amp Parikh S V (2014 June 18) Differential diagnosis and evaluation of glomerular disease (R J Glassock amp A Q Lam Eds) Retrieved May 7 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsdifferential-diagnosis-and-evaluation-of-glomerular-disease
bull Inker L Perrone R D Sterns R H amp Forman J P (2017 March 7) Assessment of kidney function Retrieved from UpToDate httpswww-uptodate-comproxywichitaeducontentsassessment-of-kidney-functionsource=search_resultampsearch=creatinineampselectedTitle=1~150
BIBLIOGRAPHY
bull James P A Ortiz E amp Et Al (2014) Evidence based guideline for the management of high blood pressure in adults (JNC) JAMA 311(5) 507-520
bull Kidney Disease Improving Global Outcomes (KDIGO) CKD Work Group (2013 January) KDIGO 2012 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease Retrieved from Kidney International Supplement httpwwwkidney-internationalorg
bull Kunz R Friedrich C Wolbers M amp Mann J F (2008) Meta-analysis effect of monotherapy and combination therapy with inhibitors of the renin angiotensin system on proteinuria in renal disease Annals of Internal Medicine 148(1) 30-48
bull Levey A Stevens L A Schmid C H Castro A F Feldman H I Kusek J W Coresh J (2009) A new equation to estimate glomerular filtration rate Annals of Internal Medicine 150(9) 604-612
bull Levin A Bakris G L Molitch M Smulders M M Williams L A amp Andress D L (2007 Jan) Prevalence of abnormal serum vitamin D PTH calcium and phosphorus in patients with chronic kidney disease results of the study to evaluate early kidney disease Kidney International 71(1) 31-38 Retrieved from PubMED
bull Mahajan A Simoni J Sheather S Broglio K Rajab M amp Wesson D (2010) Daily oral sodium bicarbonate preserves glomerular filtration rate by slowing its decline in early hypertensive nephropathy Kidney International (78_ 303-309
bull Mann J Schmieder R E amp McQueen M (2008) Renal outcomes with telmisartan ramipril or both in people at high vascular risk (the ONTARGET study) a multicentre randomised doubleblind ocntrolled trial Lancet 372(9638) 547-533
BIBLIOGRAPHY
bull Matovinović M S (2009) Pathophysiology and classification of kidney disease Retrieved from The Journal of the International Federation of Clinical Chemistry and Laboratory Medicine httpwwwifccorgifccfilesdocs20010902pdf
bull Moe S Drueke T Lameire N amp Eknoyan G (2007 Jan) Chronic kidney disease-mineral-bone disorder a new paradigmdoi101053jackd200610005
bull Murtagh F E Marsh J E Donohoe P Ekbal N J Sheerin N S amp Harris F E (2007 July) Dialysis or not A comparative survival study of patients over 75 years with chronic kidney disease stage 5 Retrieved from Nephrology Dialysis and Transplant 22(7) httpswwwncbinlmnihgovpubmed17412702
bull National Kidney Foundation (2002) KDOQI clinical practice guidelines for chronic kidney disease evaluation classification andstratification American Journal of Kidney Disease S1-S266
bull National Kidney Foundation (2014 November 5) Fact Sheets Retrieved from httpwwwkidneyorgnewsnewsroomfactsheetsFastFacts
bull Pal S (2012 June 2) Trends in chronic kidney disease Retrieved from US Pharmacist (37)6 httpswwwuspharmacistcomarticletrends-in-chronic-kidney-disease
bull Qunibi W amp Henrich W L (2017 Jan 19) Overview of chronic kidney disease-mineral and bone disorder (J Berns amp A M Sheridan Eds) Retrieved from UpToDate httpswww-uptodate-comoverview-of-chronic-kidney-disease-mineral-and-bone-disorder-ckd-mbd
bull Rosenberg M (2016 Feb 24) Overview of the management of chronic kidney disease in adults (G C Curhan amp A M Sheridan Eds) Retrieved from UpToDate UpToDate httpswww-uptodate-comproxywichitaeducontentsoverview-of-the-management-of-chronic-kidney-disease-in-adults
BIBLIOGRAPHY
bull Szczech L Stewart R C Hsu-Lin S DeLosky R J Astor B C Fox C H Vassalotti J A (2014) Primary care detection of chronic kidney disease in adults with type 2 diabetes The ADD-CKD Study (Awareness Detection and Drug Therapy in type 2 diabetes and chronic kidney disease PLOS doihttpsdoiorg101371journalpone0110535
bull USRDS (2016) Annual data report 2016 Epidemiology of kidney disease in the United States Retrieved from United States Renal Data System httpswwwusrdsorgadraspx
bull Vasudev B amp Vasudev M (2012) A model curriculum for residents rotating in nephrology MedEDPORTAL doihttpdoiorg1015766mep_2374-82658288
bull Wei L MacDonald T M Jennings C Sheng X amp Flynn R W (2013) Estimated GFR reporting is associated with decreased nonsteroidal anti-inflammatory drug prescribing and increased renal function Kidney International (84)1 174-178
chronic kidney disease in primary care
CKD as a Public Health Issue
Slide Number 3
Costs of CKD in 2013 dollarsUSRDS report
Steps to CKD Patient Care
Renal anatomy and physiology
Definition of Chronic Kidney Disease
CKD Risk Factors
Gaps in CKD Diagnosis
Slide Number 10
Steps to CKD Patient Care
creatinine
Glomerular filtration rate
Slide Number 14
Slide Number 15
Use These Equations Cautiously if at all in hellip
lab albumin creatinine ratio
The New CKD Categories
Steps to CKD Patient Care
Slide Number 20
Kidney Involvement in Systemic Diseases
Slide Number 22
Slide Number 23
DysmorphicRenal Hematuria
Slide Number 25
If you have albuminuria or hematuria-order the following labs
Prevalence of Abnormalities of Mineral Metabolism PTH in CKD
Managing CKD-MBD complications
CKD-MBD Testing
Anemia Becomes More Common as Kidney Function Declines
Detect and Manage CKD Complications
Complications-metabolic acidosis
Complications-vascular calcification
Hyperkalemia management
Hyperuricemia levels amp CKD
CKD monitoring levels 345
Slide Number 59
When to Refer to a Nephrologist
When to Refer
Steps to CKD Patient Care
Kidney transplantation
Starting Dialysis in the ElderlyhellipOr Not
Ckd management
Case 1
Slide Number 67
Lab results
Slide Number 69
Hypertensive nephropathy with proteinuria
Slide Number 71
Case 2
Slide Number 73
Management of CKD in Diabetes
Case 3
Case 3
Systemic Lupus Erythematosus (SLE)
SLE ndash Lupus Nephritis
Case 5
Case 5
Slide Number 81
Slide Number 82
Case study
Slide Number 84
CXR ndash Hilar Lymphadenopathy
Whats needed next
Slide Number 87
newly dx ckd
Slide Number 89
Bibliography
bibliography
bibliography
bibliography
bibliography
Stage 12
Stage 3
Stage 4
Stage 5
Hb le10 gdL
52
56
11
272
Hb gt10-le12 gdL
216
359
426
483
Hb le12 gdL
267
416
536
755
Stage 12
Stage 3
Stage 4
Stage 5
DIABETIC NEPHROPATHY 1 CAUSE OF CKDbull Clinical syndromebull Albuminuria gt30 mg 24 hrsbull Proteinuria gt500 mg24 hrsbull Hypertension developsbull Progressive increase in proteinuriabull Progressive decline in glomerular filtration rate
bull Chronic kidney disease should be attributed to diabetic nephropathies in most patients with diabetes if albuminuria and diabetic retinopathy are both present other causes of CKD should be entertained if diabetic retinopathy is absent (KDIGO 2007)
DIABETIC NEPHROPATHY MORTALITY
bull After 40 yrs of DM
bull 10 alive if proteinuria is present
bull 70 alive if proteinuria is absent
bull Heart Disease is 15 times higher risk in those with proteinuria
bull Proteinuria = death in this population
Dunkler et al 2015
GOALS OF CARE IN CKD GLUCOSE CONTROL
bull Target HbA1c ~70 (lt695 greatest chance of reducing albuminuria)bull Can be extended above 70 with comorbidities or limited life expectancy and
risk of hypoglycemiabull Risk of hypoglycemia increases as kidney function becomes impairedbull Declining kidney function may necessitate changes to diabetes medications and
bull Just having HTN can cause proteinuriabull Usually 1-2 gms of protein a daybull Treat them like a diabetic with ACEI or ARBS and tight blood
pressure controlbull JNC-8 goal lt14090 for ptrsquos with CKDbull National kidney foundation lt14090 if ckd and no proteinuria
lt13080 if proteinuria present
(James Ortiz amp Et Al 2014)
TREATING HYPERTENSIONPROTEINURIA ACEI ORARBbull Riskbenefit should be carefully assessed in the elderly and medically fragilebull Check labs after initiation
bull If less than 30 SCr increase continue and monitorbull If more than 30 SCr increase stop ACEi and evaluate for renal artery stenosis
bull Continue until contraindication arises no absolute eGFR cutoffbull Better proteinuria suppression with low Na diet and diureticsbull Avoid volume depletionbull Avoid ACEi and ARB in combination12
bull Risk of adverse events (impaired kidney function hyperkalemia)
(Kunz Friedrich Wolbers amp Mann 2008)(Mann Schmieder amp McQueen 2008)
bull In adults gt50 yrs statin when eGFR ge 60 mlmin173m2 statin or statinezetimibe combination when eGFR lt 60 mlmin173m2
bull In adults lt 50 yrs statin if history of known CAD MI DM strokebull Aspirin is indicated for secondary but not primary prevention
Kidney Disease Improving Global Outcomes (KDIGO) CKD Work Group Kidney Int Suppls 201331-150
STATINS-RENOPROTECTIVECONTROVERSY
bull HMG-CoA reductase inhibitors (statins) in high doses can cause proteinuria
bull Possibly associated with less inflammation endothelial dysfunction and scarring in the kidney because they also block inflammatory cytokines
bull Use statins for CV disease not to treat proteinuria
(Afzali and Goldsmith 2016)
MEDICINE CAUTION
bull Hold metformin when gfr lt35 mlmin
bull GFR lt50 mlmin should alert to check all doses of meds
bull No bisphosphanates lt35 mlmin
bull No NSAIDScox 2 inhibitors lt60 mlmin
bull Atenolol ndashrenal excretion
bull BACTRIM A lot of AKI
MEDICINE CAUTION
bull Lovenox-use subcut heparinbull Apixibanbull Dabigatranbull Rivaroxibanbull Lithiumbull GABAPENTIN (ckd 4 max 300mg qd ckd 5 max 300mg qod)
STEPS TO CKD PATIENT CARE
1 CKD definition and risks2 Assess GFR albuminuria3 Determine etiology4 Assess for evidence of progression5 Assess for associated complications6 Discuss dialysistransplantation
CKD-CVD-DIABETES LINK CKD IS A DISEASE MULTIPLIER
National kidney foundation 2014
KDIGO 2017
CKD-MINERAL BONE DISORDERS
bull As kidneys fail they
bull Stop activating calcitriol (the active form of Vit D)mdashcausing calcium imbalance
bull Do not remove phosphorus from bloodmdashleading to phosphorus retention
bull The extra phosphorus pulls calcium out of bones causing them to weaken
bull High phosphorus stimulates PTH release
bull These changes (plus others) cause the start of secondary hyperparathyroidism
bull Labs
bull eGFR
bull Calcium
bull Phos
bull Vit D
bull iPTH
(Qunibi amp Henrich 2017)
PREVALENCE OF ABNORMALITIES OF MINERAL METABOLISM PTH IN CKD
bull Progression of disease ndash declining eGFR increasing proteinuria
bull Degree of proteinuria nephrotic syndrome gt 05-10 gd on ACEi or ARB therapy
bull Etiology of CKD not certain
bull Need help with disease management
bull Indications for kidney biopsy
Rosenberg 2016
WHEN TO REFER
STEPS TO CKD PATIENT CARE
1 CKD definition and risks2 Assess GFR albuminuria3 Determine etiology4 Assess for evidence of progression5 Assess for associated complications6 Discuss dialysistransplantation
KIDNEY TRANSPLANTATION
bull Treatment of choice for ESRDbull Improves quality of lifebull Waiting list time varies-3-5 yearsbull 3 year survival rate after transplantation is 83-94bull Increased risk of cancer
STARTING DIALYSIS IN THE ELDERLYhellipOR NOT
bull Among patients gt 75 yrs with stage 5 CKD who chose to NOT start dialysisbull Overall more likely to die over next 1-2 years bull But if they had ischemic heart disease or other significant comorbidity NO
DIFFERENCE in survival
bull Active disease management and supportive care may be appropriate without starting dialysis in the ill elderly
bull Palliative care does not mean ldquono carerdquo
bull Must have end-of-life discussions
(Murtagh et al 2007)
CKD MANAGEMENTbull Diagnose cause and treat underlying conditionbull Stage per guidelinesbull Slow progression of kidney disease (ACE inhibitors)bull Monitor for complicationsmdashvolume overload hyperkalemia metabolic acidosis
hyperphosphatemia anorexia fatigue htn bone diseasebull Labs cmp cbc phos Vit D 25OH iPTH urine microscopy uric acid urine
proteincr ratio-frequency based off heat map Get sono at least oncebull Vaccinate influenza hep B pneumococcalbull Eval ASCVD risk-likely needs statinbull Possible dexa (donrsquot give bisphosphonates if GFRlt35 let specialist manage)bull Refer to nephrology when eGFR is lt30 (sometimes if higher risk-refer earlier)
CASE 1
bull 55 year old man with past medical history of headaches presents to your office for his first time visit to a PCP in over 30 years
bull He has no past history of being admitted to the hospital and he does not take any OTC medsNSAIDsherbal meds He has no history of ETOH abuse smoking or drug use
bull Vitals BP 180100 mmHg pulse 80 R 18
bull Exam No JVD S1S2 regular PMI shifted to the left no gallop no abdominal bruit pulses bilaterally equal and regular no leg edema
bull What would you order
bull EKG cbc cmp ua urine proteincr ratio lipid
LAB RESULTS
bull Labs reveal a creatinine of 22 mgdL eGFR 33 Urine shows no blood or casts Urineprotein ratio shows 1 gm protein24 hrs EKG shows LVH
bull Next step in workupbull Renal ultrasound 1st then SPEP UPEP with immunofixation serum free light chains
bull Additional labs neg Renal ultrasound shows that both kidneys are slightly reduced in size and are mildly echogenic with no mass or hydronephrosis
bull What is your diagnosis
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileMain_complications_of_persistent_high_blood_pressurepngCreative Commons License associated httpcreativecommonsorglicensesby-sa30
bull 3 months Howevermdashwe have evidence of structural abnormalities Could potentially stage at G3b A3 (red on the heat map)
bull Goal blood pressure
bull JNC 8 14090 NKF 13080
bull Additional lab needed for progression monitoring
bull Cbc renal panel phos Vit D iPTH uric acid urine micro (we already have the renal sono and urine proteincr ratio and lipid)
Selective renal angiography (left lower renal artery) after successful percutaneous balloon dilatation of the stenotic lesionFibromuscular dysplasia in an accessory renal artery causing renovascular hypertension
Secondary Hypertension
Images retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileRenal_FMD2jpg and httpcommonswikimediaorgwikiFileRenal_FMDjpgCreative Commons License associated httpcreativecommonsorglicensesby20deeden (both images)
CASE 2bull OS is a 64year old Hispanic female in for DM check She has had DM for 15+ years and is currently
taking metformin 1000mg bid Lisinopril 10mg a day atorvastatin 40mg a day Labs today showed the following
bull Hgba1c 86 cmp eGFR 50 lipid WNL proteincr ratio 650mg These results are similar to her last visit
bull Upon further hx-you find that she had a recent eye exam and has mild nonproliferaive retinopathy She does not have neuropathy or other ss
bull What further workup do you need
bull Renal sonogram urine micro iPTH vit D (25 OH) phos uric acid
bull Dx stage
bull G3a A3
bull What further treatment do you need
bull Improve glycemic control Increase Lisinopril to 20mg with a goal of 40mg Avoid NSAIDs or other nephrotoxic agents make sure meds are renally dosed monitor 3xyear nephro referral
MANAGEMENT OF CKD IN DIABETESeGFR Recommended
All patients
Yearly measurement of creatinine urinary albumin excretion potassium
45-60 Referral to a nephrologist if possibility for nondiabetickidney disease existsConsider dose adjustment of medicationsMonitor eGFR every 6 monthsMonitor electrolytes bicarbonate hemoglobin calcium phosphorus parathyroid hormone at least yearly
Assure vitamin D sufficiencyConsider bone density testingReferral for dietary counselling
American Diabetes Association Standards of Medical Care in Diabetes Microvascular complications and foot care Diabetes Care 2017 40 (Suppl 1) S88-S98
CASE 3
bull 19 year old African American woman presents to your clinic with complaints of fatigue joint pains a new rash on her face oral ulcer
bull On exam BP 15080 P 88 Afebrile 96 O2 sats on RAbull GEN No respiratory distress at restbull HEENT painless oral ulcer flat rash over malar eminences sparing the nasolabial fold pallor +bull Lungs CTAbull CVS S1S2 regularbull Abdomen soft NTbull Ext left elbow joint and bilateral wrist joints are swollen and tender
bull What would you orderbull CBC CMP ua urine microscopy (microalbumin or urine proteincr ratio) ANA esr RF anti-ccp uric acid TSH
CASE 3
bull Working dx fatigue oral ulcer joint pain
bull Basic Labs Na 135 K 55 Bicarb 18 BUN 50 Cr 35 eGFR 22 Ca 90 ANA + titer 1640
bull UA 3+ blood 3+ protein RBC casts +
bull Given these results what is the most likely diagnosis
bull What would you do
SYSTEMIC LUPUS ERYTHEMATOSUS (SLE)
bull SLE multisystemic disease Etiology unknown
bull Production of autoantibodies and immune complexes formation
bull There is renal involvement in the great majority of patients with SLE at some time of the evolution 66-90
SLE ndash LUPUS NEPHRITIS
bull Race SLE is more commonsevere in African americans than Caucasiansbull
bull Gender female-to-male ratio of 91
bull Age Most patients develop lupus nephritis early in their disease course SLE is more common among women in the third decade of life and lupus nephritis occurs in patients aged 20-40 years
bull Kidney Biopsy For staging lupus nephritis (Class 1-5)
CASE 5bull A 80 year old man who has not seen a PCP in many years
presents to your clinic for weakness for the past few months On further questioning he tells you that his bones also have been hurting lately and he has developed leg swelling in the past month or so
bull On exam bull BP 16090 P 88 Afebrilebull GEN Thin built manbull HEENT pallor presentbull Lungs clearbull CVS S1S2 regular no rub or gallopbull Abdomen soft NTbull Ext 2 + edema
CASE 5
bull Differentials
bull CHF MI Cancer arthritis
bull Labs
bull CBC CMP urine microscopy urine proteincr ratio ESR TSH EKG BNP pa and lat CXR
bull LABS Urine dipstick negative for protein or blood
bull Basic chem bull Na 136 (135-145) K 51 (35-55) Chloride 108 (96-106) Bicarb 25
Given this presentation and the labs (low anion gap and elevated calcium anemia kidney failure) what will you think of What will you order next
Serum and urine protein electrophoresis
Intratubular refractile casts with surrounding syncytial giant cell reaction with chronic tubulointerstitial nephritis and fibrosis characteristic of myeloma cast nephropathy
Kidney Biopsy
CASE STUDYbull A 35 year old African American woman was seen in the clinic for
chronic cough and dyspnea on exertion She gave history of vague symptoms of fatigue and weight loss of 20 Ibs over the last six months
bull List some differentialsbull TB sarcoid lupus thyroid problems PEbull What would you orderbull PPD cbc cmp UA TSH ANA pa and lat cxr
bull Her labs were significant for mildly elevated calcium level and a creatinine of 20 mgdL eGFR 37
bull She had 750 mg of proteinuriaday
bull PPD neg ANA neg TSH and other labs WNL
bull Assuming this is present more than 3 monthshelliphellipwhat is her ckd stage
bull G3b A3
bull What do we still need
CT scan of chest
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileAnterior_mediastinal_mass_thymomajpgCreative Commons License associated httpcreativecommonsorglicensesby20deeden
CXR ndash HILAR LYMPHADENOPATHY
WHATS NEEDED NEXT
bull Biopsy of hilar lymphadenopathy or renal biopsy
bull DX sarcoidosis
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileSarcoidosis_signs_and_symptomsjpgThis work is in the public domain in the United States because it is a work of the United States Federal Government under the terms of Title 17 Chapter 1 Section 105 of the US Code
NEWLY DX CKD
bull 1) urinalysis microscopy ultrasound proteincr ratio
bull If obstruction-treat
bull No obstruction
bull Hx critical (consider myeloma if high risk)
bull glomerular bleeding or albumin in urine
bull Yes workup for glomerular causes (ANArf hep B C upep spep ANCA complement C3 C4)
bull No sterile pyruria-consider interstitial nephritis
bull High risk renovascular disease Evaluate renovascular disease
Additional Online Resources for CKD LearningbullNational Kidney Foundation wwwkidneyorgbullUnited States Renal Data Service wwwusrdsorgbullCDCrsquos CKD Surveillance Project
httpnccdcdcgovckdbullNational Kidney Disease Education Program
(NKDEP) httpnkdepnihgov
BIBLIOGRAPHY
bull Afzali B amp Goldsmith D J (2016 June 29) Statins and chronic kidney disease (G C Curhan amp A M Sheridan Eds) Retrieved 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsstatins-and-chronic-kidney-disease
bull American Diabetes Association Standards of Medical Care in Diabetes (2017) Microvascular complications and foot care Diabetes Care 2017 (40) S88-S98
bull American Diabetes Association Standards of Medical Care in Diabetes (2017) Microvascular complications and foot care Diabetes Care 40 (suppl 1) S88-S98
bull Berns J S (2017 Mar 22) Treatment of anemia in nondialysis chronic kidney disease (T A Golper amp A M Sheridan Eds) Retrieved from UpToDate httpswww-uptodate-comproxywichitaeducontentstreatment-of-anemia-in-nondialysis-chronic-kidney-disease
bull Chan M Dall A T Fletcher K E Lu N amp Trivedi H (2007) Outcomes in patients with chronic kidney disease referred late to nephrologists a meta-analysis American Journal of Medicine 120(12) 1063-1070
bull Coresh J Selvin E amp Stevens L A (2007) Prevalence of chronic kidny disease in the United States JAMA 298(17) doi101001jama298172038
bull de Brito-Ashurst I Varagunam M Raftery M amp Yagoob M (2009) Bicarbonate supplementation slows progression of CKD and improves nutritional status Journal of American Society of Nephrology (20) 2075-2084
BIBLIOGRAPHY
bull Duncan L Heathcoat J Djurdjev O amp Levin A (2001) Screening for renal disease using serum creatinine who are we missing Nephrology Dialysis and Transplant 16(5) 1042-1046
bull Dunkler D Gao P Lee S F Heinz G Clase C M Tobe S Oberbauer R (2015 August 7) Risk prediction for early CKD in type 2 diabetes Retrieved from Clinical Journal of the American Society of Nephrology httpcjasnasnjournalsorgcontent1081371fullsid=61422554-a5f1-41ac-b696-dcd3b12bd268
bull Fatehi P amp Chi-yuan H (September 15 2016) Diagnostic approach to the patient with newly identified chronic kidney disease (G C Curhan amp A M Sheridan Eds) Retrieved May 7 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsdiagnostic-approach-to-the-patient-with-newly-identified-chronic-kidney-disease
bull Fink J e (2009) Chronic Kidney Disease as an Under-Recognized Threat to Patient Safety American journal of kidney diseases the official journal of the National Kidney Foundation 53(4) 681-688
bull Gaffo A L amp Saag K G (2008 Nov) Management of hyperuricemia and gout in CKD doihttpdxdoiorg101053jajkd200807035
bull Hebert L A amp Parikh S V (2014 June 18) Differential diagnosis and evaluation of glomerular disease (R J Glassock amp A Q Lam Eds) Retrieved May 7 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsdifferential-diagnosis-and-evaluation-of-glomerular-disease
bull Inker L Perrone R D Sterns R H amp Forman J P (2017 March 7) Assessment of kidney function Retrieved from UpToDate httpswww-uptodate-comproxywichitaeducontentsassessment-of-kidney-functionsource=search_resultampsearch=creatinineampselectedTitle=1~150
BIBLIOGRAPHY
bull James P A Ortiz E amp Et Al (2014) Evidence based guideline for the management of high blood pressure in adults (JNC) JAMA 311(5) 507-520
bull Kidney Disease Improving Global Outcomes (KDIGO) CKD Work Group (2013 January) KDIGO 2012 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease Retrieved from Kidney International Supplement httpwwwkidney-internationalorg
bull Kunz R Friedrich C Wolbers M amp Mann J F (2008) Meta-analysis effect of monotherapy and combination therapy with inhibitors of the renin angiotensin system on proteinuria in renal disease Annals of Internal Medicine 148(1) 30-48
bull Levey A Stevens L A Schmid C H Castro A F Feldman H I Kusek J W Coresh J (2009) A new equation to estimate glomerular filtration rate Annals of Internal Medicine 150(9) 604-612
bull Levin A Bakris G L Molitch M Smulders M M Williams L A amp Andress D L (2007 Jan) Prevalence of abnormal serum vitamin D PTH calcium and phosphorus in patients with chronic kidney disease results of the study to evaluate early kidney disease Kidney International 71(1) 31-38 Retrieved from PubMED
bull Mahajan A Simoni J Sheather S Broglio K Rajab M amp Wesson D (2010) Daily oral sodium bicarbonate preserves glomerular filtration rate by slowing its decline in early hypertensive nephropathy Kidney International (78_ 303-309
bull Mann J Schmieder R E amp McQueen M (2008) Renal outcomes with telmisartan ramipril or both in people at high vascular risk (the ONTARGET study) a multicentre randomised doubleblind ocntrolled trial Lancet 372(9638) 547-533
BIBLIOGRAPHY
bull Matovinović M S (2009) Pathophysiology and classification of kidney disease Retrieved from The Journal of the International Federation of Clinical Chemistry and Laboratory Medicine httpwwwifccorgifccfilesdocs20010902pdf
bull Moe S Drueke T Lameire N amp Eknoyan G (2007 Jan) Chronic kidney disease-mineral-bone disorder a new paradigmdoi101053jackd200610005
bull Murtagh F E Marsh J E Donohoe P Ekbal N J Sheerin N S amp Harris F E (2007 July) Dialysis or not A comparative survival study of patients over 75 years with chronic kidney disease stage 5 Retrieved from Nephrology Dialysis and Transplant 22(7) httpswwwncbinlmnihgovpubmed17412702
bull National Kidney Foundation (2002) KDOQI clinical practice guidelines for chronic kidney disease evaluation classification andstratification American Journal of Kidney Disease S1-S266
bull National Kidney Foundation (2014 November 5) Fact Sheets Retrieved from httpwwwkidneyorgnewsnewsroomfactsheetsFastFacts
bull Pal S (2012 June 2) Trends in chronic kidney disease Retrieved from US Pharmacist (37)6 httpswwwuspharmacistcomarticletrends-in-chronic-kidney-disease
bull Qunibi W amp Henrich W L (2017 Jan 19) Overview of chronic kidney disease-mineral and bone disorder (J Berns amp A M Sheridan Eds) Retrieved from UpToDate httpswww-uptodate-comoverview-of-chronic-kidney-disease-mineral-and-bone-disorder-ckd-mbd
bull Rosenberg M (2016 Feb 24) Overview of the management of chronic kidney disease in adults (G C Curhan amp A M Sheridan Eds) Retrieved from UpToDate UpToDate httpswww-uptodate-comproxywichitaeducontentsoverview-of-the-management-of-chronic-kidney-disease-in-adults
BIBLIOGRAPHY
bull Szczech L Stewart R C Hsu-Lin S DeLosky R J Astor B C Fox C H Vassalotti J A (2014) Primary care detection of chronic kidney disease in adults with type 2 diabetes The ADD-CKD Study (Awareness Detection and Drug Therapy in type 2 diabetes and chronic kidney disease PLOS doihttpsdoiorg101371journalpone0110535
bull USRDS (2016) Annual data report 2016 Epidemiology of kidney disease in the United States Retrieved from United States Renal Data System httpswwwusrdsorgadraspx
bull Vasudev B amp Vasudev M (2012) A model curriculum for residents rotating in nephrology MedEDPORTAL doihttpdoiorg1015766mep_2374-82658288
bull Wei L MacDonald T M Jennings C Sheng X amp Flynn R W (2013) Estimated GFR reporting is associated with decreased nonsteroidal anti-inflammatory drug prescribing and increased renal function Kidney International (84)1 174-178
chronic kidney disease in primary care
CKD as a Public Health Issue
Slide Number 3
Costs of CKD in 2013 dollarsUSRDS report
Steps to CKD Patient Care
Renal anatomy and physiology
Definition of Chronic Kidney Disease
CKD Risk Factors
Gaps in CKD Diagnosis
Slide Number 10
Steps to CKD Patient Care
creatinine
Glomerular filtration rate
Slide Number 14
Slide Number 15
Use These Equations Cautiously if at all in hellip
lab albumin creatinine ratio
The New CKD Categories
Steps to CKD Patient Care
Slide Number 20
Kidney Involvement in Systemic Diseases
Slide Number 22
Slide Number 23
DysmorphicRenal Hematuria
Slide Number 25
If you have albuminuria or hematuria-order the following labs
Prevalence of Abnormalities of Mineral Metabolism PTH in CKD
Managing CKD-MBD complications
CKD-MBD Testing
Anemia Becomes More Common as Kidney Function Declines
Detect and Manage CKD Complications
Complications-metabolic acidosis
Complications-vascular calcification
Hyperkalemia management
Hyperuricemia levels amp CKD
CKD monitoring levels 345
Slide Number 59
When to Refer to a Nephrologist
When to Refer
Steps to CKD Patient Care
Kidney transplantation
Starting Dialysis in the ElderlyhellipOr Not
Ckd management
Case 1
Slide Number 67
Lab results
Slide Number 69
Hypertensive nephropathy with proteinuria
Slide Number 71
Case 2
Slide Number 73
Management of CKD in Diabetes
Case 3
Case 3
Systemic Lupus Erythematosus (SLE)
SLE ndash Lupus Nephritis
Case 5
Case 5
Slide Number 81
Slide Number 82
Case study
Slide Number 84
CXR ndash Hilar Lymphadenopathy
Whats needed next
Slide Number 87
newly dx ckd
Slide Number 89
Bibliography
bibliography
bibliography
bibliography
bibliography
Stage 12
Stage 3
Stage 4
Stage 5
Hb le10 gdL
52
56
11
272
Hb gt10-le12 gdL
216
359
426
483
Hb le12 gdL
267
416
536
755
Stage 12
Stage 3
Stage 4
Stage 5
DIABETIC NEPHROPATHY MORTALITY
bull After 40 yrs of DM
bull 10 alive if proteinuria is present
bull 70 alive if proteinuria is absent
bull Heart Disease is 15 times higher risk in those with proteinuria
bull Proteinuria = death in this population
Dunkler et al 2015
GOALS OF CARE IN CKD GLUCOSE CONTROL
bull Target HbA1c ~70 (lt695 greatest chance of reducing albuminuria)bull Can be extended above 70 with comorbidities or limited life expectancy and
risk of hypoglycemiabull Risk of hypoglycemia increases as kidney function becomes impairedbull Declining kidney function may necessitate changes to diabetes medications and
bull Just having HTN can cause proteinuriabull Usually 1-2 gms of protein a daybull Treat them like a diabetic with ACEI or ARBS and tight blood
pressure controlbull JNC-8 goal lt14090 for ptrsquos with CKDbull National kidney foundation lt14090 if ckd and no proteinuria
lt13080 if proteinuria present
(James Ortiz amp Et Al 2014)
TREATING HYPERTENSIONPROTEINURIA ACEI ORARBbull Riskbenefit should be carefully assessed in the elderly and medically fragilebull Check labs after initiation
bull If less than 30 SCr increase continue and monitorbull If more than 30 SCr increase stop ACEi and evaluate for renal artery stenosis
bull Continue until contraindication arises no absolute eGFR cutoffbull Better proteinuria suppression with low Na diet and diureticsbull Avoid volume depletionbull Avoid ACEi and ARB in combination12
bull Risk of adverse events (impaired kidney function hyperkalemia)
(Kunz Friedrich Wolbers amp Mann 2008)(Mann Schmieder amp McQueen 2008)
bull In adults gt50 yrs statin when eGFR ge 60 mlmin173m2 statin or statinezetimibe combination when eGFR lt 60 mlmin173m2
bull In adults lt 50 yrs statin if history of known CAD MI DM strokebull Aspirin is indicated for secondary but not primary prevention
Kidney Disease Improving Global Outcomes (KDIGO) CKD Work Group Kidney Int Suppls 201331-150
STATINS-RENOPROTECTIVECONTROVERSY
bull HMG-CoA reductase inhibitors (statins) in high doses can cause proteinuria
bull Possibly associated with less inflammation endothelial dysfunction and scarring in the kidney because they also block inflammatory cytokines
bull Use statins for CV disease not to treat proteinuria
(Afzali and Goldsmith 2016)
MEDICINE CAUTION
bull Hold metformin when gfr lt35 mlmin
bull GFR lt50 mlmin should alert to check all doses of meds
bull No bisphosphanates lt35 mlmin
bull No NSAIDScox 2 inhibitors lt60 mlmin
bull Atenolol ndashrenal excretion
bull BACTRIM A lot of AKI
MEDICINE CAUTION
bull Lovenox-use subcut heparinbull Apixibanbull Dabigatranbull Rivaroxibanbull Lithiumbull GABAPENTIN (ckd 4 max 300mg qd ckd 5 max 300mg qod)
STEPS TO CKD PATIENT CARE
1 CKD definition and risks2 Assess GFR albuminuria3 Determine etiology4 Assess for evidence of progression5 Assess for associated complications6 Discuss dialysistransplantation
CKD-CVD-DIABETES LINK CKD IS A DISEASE MULTIPLIER
National kidney foundation 2014
KDIGO 2017
CKD-MINERAL BONE DISORDERS
bull As kidneys fail they
bull Stop activating calcitriol (the active form of Vit D)mdashcausing calcium imbalance
bull Do not remove phosphorus from bloodmdashleading to phosphorus retention
bull The extra phosphorus pulls calcium out of bones causing them to weaken
bull High phosphorus stimulates PTH release
bull These changes (plus others) cause the start of secondary hyperparathyroidism
bull Labs
bull eGFR
bull Calcium
bull Phos
bull Vit D
bull iPTH
(Qunibi amp Henrich 2017)
PREVALENCE OF ABNORMALITIES OF MINERAL METABOLISM PTH IN CKD
bull Progression of disease ndash declining eGFR increasing proteinuria
bull Degree of proteinuria nephrotic syndrome gt 05-10 gd on ACEi or ARB therapy
bull Etiology of CKD not certain
bull Need help with disease management
bull Indications for kidney biopsy
Rosenberg 2016
WHEN TO REFER
STEPS TO CKD PATIENT CARE
1 CKD definition and risks2 Assess GFR albuminuria3 Determine etiology4 Assess for evidence of progression5 Assess for associated complications6 Discuss dialysistransplantation
KIDNEY TRANSPLANTATION
bull Treatment of choice for ESRDbull Improves quality of lifebull Waiting list time varies-3-5 yearsbull 3 year survival rate after transplantation is 83-94bull Increased risk of cancer
STARTING DIALYSIS IN THE ELDERLYhellipOR NOT
bull Among patients gt 75 yrs with stage 5 CKD who chose to NOT start dialysisbull Overall more likely to die over next 1-2 years bull But if they had ischemic heart disease or other significant comorbidity NO
DIFFERENCE in survival
bull Active disease management and supportive care may be appropriate without starting dialysis in the ill elderly
bull Palliative care does not mean ldquono carerdquo
bull Must have end-of-life discussions
(Murtagh et al 2007)
CKD MANAGEMENTbull Diagnose cause and treat underlying conditionbull Stage per guidelinesbull Slow progression of kidney disease (ACE inhibitors)bull Monitor for complicationsmdashvolume overload hyperkalemia metabolic acidosis
hyperphosphatemia anorexia fatigue htn bone diseasebull Labs cmp cbc phos Vit D 25OH iPTH urine microscopy uric acid urine
proteincr ratio-frequency based off heat map Get sono at least oncebull Vaccinate influenza hep B pneumococcalbull Eval ASCVD risk-likely needs statinbull Possible dexa (donrsquot give bisphosphonates if GFRlt35 let specialist manage)bull Refer to nephrology when eGFR is lt30 (sometimes if higher risk-refer earlier)
CASE 1
bull 55 year old man with past medical history of headaches presents to your office for his first time visit to a PCP in over 30 years
bull He has no past history of being admitted to the hospital and he does not take any OTC medsNSAIDsherbal meds He has no history of ETOH abuse smoking or drug use
bull Vitals BP 180100 mmHg pulse 80 R 18
bull Exam No JVD S1S2 regular PMI shifted to the left no gallop no abdominal bruit pulses bilaterally equal and regular no leg edema
bull What would you order
bull EKG cbc cmp ua urine proteincr ratio lipid
LAB RESULTS
bull Labs reveal a creatinine of 22 mgdL eGFR 33 Urine shows no blood or casts Urineprotein ratio shows 1 gm protein24 hrs EKG shows LVH
bull Next step in workupbull Renal ultrasound 1st then SPEP UPEP with immunofixation serum free light chains
bull Additional labs neg Renal ultrasound shows that both kidneys are slightly reduced in size and are mildly echogenic with no mass or hydronephrosis
bull What is your diagnosis
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileMain_complications_of_persistent_high_blood_pressurepngCreative Commons License associated httpcreativecommonsorglicensesby-sa30
bull 3 months Howevermdashwe have evidence of structural abnormalities Could potentially stage at G3b A3 (red on the heat map)
bull Goal blood pressure
bull JNC 8 14090 NKF 13080
bull Additional lab needed for progression monitoring
bull Cbc renal panel phos Vit D iPTH uric acid urine micro (we already have the renal sono and urine proteincr ratio and lipid)
Selective renal angiography (left lower renal artery) after successful percutaneous balloon dilatation of the stenotic lesionFibromuscular dysplasia in an accessory renal artery causing renovascular hypertension
Secondary Hypertension
Images retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileRenal_FMD2jpg and httpcommonswikimediaorgwikiFileRenal_FMDjpgCreative Commons License associated httpcreativecommonsorglicensesby20deeden (both images)
CASE 2bull OS is a 64year old Hispanic female in for DM check She has had DM for 15+ years and is currently
taking metformin 1000mg bid Lisinopril 10mg a day atorvastatin 40mg a day Labs today showed the following
bull Hgba1c 86 cmp eGFR 50 lipid WNL proteincr ratio 650mg These results are similar to her last visit
bull Upon further hx-you find that she had a recent eye exam and has mild nonproliferaive retinopathy She does not have neuropathy or other ss
bull What further workup do you need
bull Renal sonogram urine micro iPTH vit D (25 OH) phos uric acid
bull Dx stage
bull G3a A3
bull What further treatment do you need
bull Improve glycemic control Increase Lisinopril to 20mg with a goal of 40mg Avoid NSAIDs or other nephrotoxic agents make sure meds are renally dosed monitor 3xyear nephro referral
MANAGEMENT OF CKD IN DIABETESeGFR Recommended
All patients
Yearly measurement of creatinine urinary albumin excretion potassium
45-60 Referral to a nephrologist if possibility for nondiabetickidney disease existsConsider dose adjustment of medicationsMonitor eGFR every 6 monthsMonitor electrolytes bicarbonate hemoglobin calcium phosphorus parathyroid hormone at least yearly
Assure vitamin D sufficiencyConsider bone density testingReferral for dietary counselling
American Diabetes Association Standards of Medical Care in Diabetes Microvascular complications and foot care Diabetes Care 2017 40 (Suppl 1) S88-S98
CASE 3
bull 19 year old African American woman presents to your clinic with complaints of fatigue joint pains a new rash on her face oral ulcer
bull On exam BP 15080 P 88 Afebrile 96 O2 sats on RAbull GEN No respiratory distress at restbull HEENT painless oral ulcer flat rash over malar eminences sparing the nasolabial fold pallor +bull Lungs CTAbull CVS S1S2 regularbull Abdomen soft NTbull Ext left elbow joint and bilateral wrist joints are swollen and tender
bull What would you orderbull CBC CMP ua urine microscopy (microalbumin or urine proteincr ratio) ANA esr RF anti-ccp uric acid TSH
CASE 3
bull Working dx fatigue oral ulcer joint pain
bull Basic Labs Na 135 K 55 Bicarb 18 BUN 50 Cr 35 eGFR 22 Ca 90 ANA + titer 1640
bull UA 3+ blood 3+ protein RBC casts +
bull Given these results what is the most likely diagnosis
bull What would you do
SYSTEMIC LUPUS ERYTHEMATOSUS (SLE)
bull SLE multisystemic disease Etiology unknown
bull Production of autoantibodies and immune complexes formation
bull There is renal involvement in the great majority of patients with SLE at some time of the evolution 66-90
SLE ndash LUPUS NEPHRITIS
bull Race SLE is more commonsevere in African americans than Caucasiansbull
bull Gender female-to-male ratio of 91
bull Age Most patients develop lupus nephritis early in their disease course SLE is more common among women in the third decade of life and lupus nephritis occurs in patients aged 20-40 years
bull Kidney Biopsy For staging lupus nephritis (Class 1-5)
CASE 5bull A 80 year old man who has not seen a PCP in many years
presents to your clinic for weakness for the past few months On further questioning he tells you that his bones also have been hurting lately and he has developed leg swelling in the past month or so
bull On exam bull BP 16090 P 88 Afebrilebull GEN Thin built manbull HEENT pallor presentbull Lungs clearbull CVS S1S2 regular no rub or gallopbull Abdomen soft NTbull Ext 2 + edema
CASE 5
bull Differentials
bull CHF MI Cancer arthritis
bull Labs
bull CBC CMP urine microscopy urine proteincr ratio ESR TSH EKG BNP pa and lat CXR
bull LABS Urine dipstick negative for protein or blood
bull Basic chem bull Na 136 (135-145) K 51 (35-55) Chloride 108 (96-106) Bicarb 25
Given this presentation and the labs (low anion gap and elevated calcium anemia kidney failure) what will you think of What will you order next
Serum and urine protein electrophoresis
Intratubular refractile casts with surrounding syncytial giant cell reaction with chronic tubulointerstitial nephritis and fibrosis characteristic of myeloma cast nephropathy
Kidney Biopsy
CASE STUDYbull A 35 year old African American woman was seen in the clinic for
chronic cough and dyspnea on exertion She gave history of vague symptoms of fatigue and weight loss of 20 Ibs over the last six months
bull List some differentialsbull TB sarcoid lupus thyroid problems PEbull What would you orderbull PPD cbc cmp UA TSH ANA pa and lat cxr
bull Her labs were significant for mildly elevated calcium level and a creatinine of 20 mgdL eGFR 37
bull She had 750 mg of proteinuriaday
bull PPD neg ANA neg TSH and other labs WNL
bull Assuming this is present more than 3 monthshelliphellipwhat is her ckd stage
bull G3b A3
bull What do we still need
CT scan of chest
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileAnterior_mediastinal_mass_thymomajpgCreative Commons License associated httpcreativecommonsorglicensesby20deeden
CXR ndash HILAR LYMPHADENOPATHY
WHATS NEEDED NEXT
bull Biopsy of hilar lymphadenopathy or renal biopsy
bull DX sarcoidosis
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileSarcoidosis_signs_and_symptomsjpgThis work is in the public domain in the United States because it is a work of the United States Federal Government under the terms of Title 17 Chapter 1 Section 105 of the US Code
NEWLY DX CKD
bull 1) urinalysis microscopy ultrasound proteincr ratio
bull If obstruction-treat
bull No obstruction
bull Hx critical (consider myeloma if high risk)
bull glomerular bleeding or albumin in urine
bull Yes workup for glomerular causes (ANArf hep B C upep spep ANCA complement C3 C4)
bull No sterile pyruria-consider interstitial nephritis
bull High risk renovascular disease Evaluate renovascular disease
Additional Online Resources for CKD LearningbullNational Kidney Foundation wwwkidneyorgbullUnited States Renal Data Service wwwusrdsorgbullCDCrsquos CKD Surveillance Project
httpnccdcdcgovckdbullNational Kidney Disease Education Program
(NKDEP) httpnkdepnihgov
BIBLIOGRAPHY
bull Afzali B amp Goldsmith D J (2016 June 29) Statins and chronic kidney disease (G C Curhan amp A M Sheridan Eds) Retrieved 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsstatins-and-chronic-kidney-disease
bull American Diabetes Association Standards of Medical Care in Diabetes (2017) Microvascular complications and foot care Diabetes Care 2017 (40) S88-S98
bull American Diabetes Association Standards of Medical Care in Diabetes (2017) Microvascular complications and foot care Diabetes Care 40 (suppl 1) S88-S98
bull Berns J S (2017 Mar 22) Treatment of anemia in nondialysis chronic kidney disease (T A Golper amp A M Sheridan Eds) Retrieved from UpToDate httpswww-uptodate-comproxywichitaeducontentstreatment-of-anemia-in-nondialysis-chronic-kidney-disease
bull Chan M Dall A T Fletcher K E Lu N amp Trivedi H (2007) Outcomes in patients with chronic kidney disease referred late to nephrologists a meta-analysis American Journal of Medicine 120(12) 1063-1070
bull Coresh J Selvin E amp Stevens L A (2007) Prevalence of chronic kidny disease in the United States JAMA 298(17) doi101001jama298172038
bull de Brito-Ashurst I Varagunam M Raftery M amp Yagoob M (2009) Bicarbonate supplementation slows progression of CKD and improves nutritional status Journal of American Society of Nephrology (20) 2075-2084
BIBLIOGRAPHY
bull Duncan L Heathcoat J Djurdjev O amp Levin A (2001) Screening for renal disease using serum creatinine who are we missing Nephrology Dialysis and Transplant 16(5) 1042-1046
bull Dunkler D Gao P Lee S F Heinz G Clase C M Tobe S Oberbauer R (2015 August 7) Risk prediction for early CKD in type 2 diabetes Retrieved from Clinical Journal of the American Society of Nephrology httpcjasnasnjournalsorgcontent1081371fullsid=61422554-a5f1-41ac-b696-dcd3b12bd268
bull Fatehi P amp Chi-yuan H (September 15 2016) Diagnostic approach to the patient with newly identified chronic kidney disease (G C Curhan amp A M Sheridan Eds) Retrieved May 7 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsdiagnostic-approach-to-the-patient-with-newly-identified-chronic-kidney-disease
bull Fink J e (2009) Chronic Kidney Disease as an Under-Recognized Threat to Patient Safety American journal of kidney diseases the official journal of the National Kidney Foundation 53(4) 681-688
bull Gaffo A L amp Saag K G (2008 Nov) Management of hyperuricemia and gout in CKD doihttpdxdoiorg101053jajkd200807035
bull Hebert L A amp Parikh S V (2014 June 18) Differential diagnosis and evaluation of glomerular disease (R J Glassock amp A Q Lam Eds) Retrieved May 7 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsdifferential-diagnosis-and-evaluation-of-glomerular-disease
bull Inker L Perrone R D Sterns R H amp Forman J P (2017 March 7) Assessment of kidney function Retrieved from UpToDate httpswww-uptodate-comproxywichitaeducontentsassessment-of-kidney-functionsource=search_resultampsearch=creatinineampselectedTitle=1~150
BIBLIOGRAPHY
bull James P A Ortiz E amp Et Al (2014) Evidence based guideline for the management of high blood pressure in adults (JNC) JAMA 311(5) 507-520
bull Kidney Disease Improving Global Outcomes (KDIGO) CKD Work Group (2013 January) KDIGO 2012 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease Retrieved from Kidney International Supplement httpwwwkidney-internationalorg
bull Kunz R Friedrich C Wolbers M amp Mann J F (2008) Meta-analysis effect of monotherapy and combination therapy with inhibitors of the renin angiotensin system on proteinuria in renal disease Annals of Internal Medicine 148(1) 30-48
bull Levey A Stevens L A Schmid C H Castro A F Feldman H I Kusek J W Coresh J (2009) A new equation to estimate glomerular filtration rate Annals of Internal Medicine 150(9) 604-612
bull Levin A Bakris G L Molitch M Smulders M M Williams L A amp Andress D L (2007 Jan) Prevalence of abnormal serum vitamin D PTH calcium and phosphorus in patients with chronic kidney disease results of the study to evaluate early kidney disease Kidney International 71(1) 31-38 Retrieved from PubMED
bull Mahajan A Simoni J Sheather S Broglio K Rajab M amp Wesson D (2010) Daily oral sodium bicarbonate preserves glomerular filtration rate by slowing its decline in early hypertensive nephropathy Kidney International (78_ 303-309
bull Mann J Schmieder R E amp McQueen M (2008) Renal outcomes with telmisartan ramipril or both in people at high vascular risk (the ONTARGET study) a multicentre randomised doubleblind ocntrolled trial Lancet 372(9638) 547-533
BIBLIOGRAPHY
bull Matovinović M S (2009) Pathophysiology and classification of kidney disease Retrieved from The Journal of the International Federation of Clinical Chemistry and Laboratory Medicine httpwwwifccorgifccfilesdocs20010902pdf
bull Moe S Drueke T Lameire N amp Eknoyan G (2007 Jan) Chronic kidney disease-mineral-bone disorder a new paradigmdoi101053jackd200610005
bull Murtagh F E Marsh J E Donohoe P Ekbal N J Sheerin N S amp Harris F E (2007 July) Dialysis or not A comparative survival study of patients over 75 years with chronic kidney disease stage 5 Retrieved from Nephrology Dialysis and Transplant 22(7) httpswwwncbinlmnihgovpubmed17412702
bull National Kidney Foundation (2002) KDOQI clinical practice guidelines for chronic kidney disease evaluation classification andstratification American Journal of Kidney Disease S1-S266
bull National Kidney Foundation (2014 November 5) Fact Sheets Retrieved from httpwwwkidneyorgnewsnewsroomfactsheetsFastFacts
bull Pal S (2012 June 2) Trends in chronic kidney disease Retrieved from US Pharmacist (37)6 httpswwwuspharmacistcomarticletrends-in-chronic-kidney-disease
bull Qunibi W amp Henrich W L (2017 Jan 19) Overview of chronic kidney disease-mineral and bone disorder (J Berns amp A M Sheridan Eds) Retrieved from UpToDate httpswww-uptodate-comoverview-of-chronic-kidney-disease-mineral-and-bone-disorder-ckd-mbd
bull Rosenberg M (2016 Feb 24) Overview of the management of chronic kidney disease in adults (G C Curhan amp A M Sheridan Eds) Retrieved from UpToDate UpToDate httpswww-uptodate-comproxywichitaeducontentsoverview-of-the-management-of-chronic-kidney-disease-in-adults
BIBLIOGRAPHY
bull Szczech L Stewart R C Hsu-Lin S DeLosky R J Astor B C Fox C H Vassalotti J A (2014) Primary care detection of chronic kidney disease in adults with type 2 diabetes The ADD-CKD Study (Awareness Detection and Drug Therapy in type 2 diabetes and chronic kidney disease PLOS doihttpsdoiorg101371journalpone0110535
bull USRDS (2016) Annual data report 2016 Epidemiology of kidney disease in the United States Retrieved from United States Renal Data System httpswwwusrdsorgadraspx
bull Vasudev B amp Vasudev M (2012) A model curriculum for residents rotating in nephrology MedEDPORTAL doihttpdoiorg1015766mep_2374-82658288
bull Wei L MacDonald T M Jennings C Sheng X amp Flynn R W (2013) Estimated GFR reporting is associated with decreased nonsteroidal anti-inflammatory drug prescribing and increased renal function Kidney International (84)1 174-178
chronic kidney disease in primary care
CKD as a Public Health Issue
Slide Number 3
Costs of CKD in 2013 dollarsUSRDS report
Steps to CKD Patient Care
Renal anatomy and physiology
Definition of Chronic Kidney Disease
CKD Risk Factors
Gaps in CKD Diagnosis
Slide Number 10
Steps to CKD Patient Care
creatinine
Glomerular filtration rate
Slide Number 14
Slide Number 15
Use These Equations Cautiously if at all in hellip
lab albumin creatinine ratio
The New CKD Categories
Steps to CKD Patient Care
Slide Number 20
Kidney Involvement in Systemic Diseases
Slide Number 22
Slide Number 23
DysmorphicRenal Hematuria
Slide Number 25
If you have albuminuria or hematuria-order the following labs
Prevalence of Abnormalities of Mineral Metabolism PTH in CKD
Managing CKD-MBD complications
CKD-MBD Testing
Anemia Becomes More Common as Kidney Function Declines
Detect and Manage CKD Complications
Complications-metabolic acidosis
Complications-vascular calcification
Hyperkalemia management
Hyperuricemia levels amp CKD
CKD monitoring levels 345
Slide Number 59
When to Refer to a Nephrologist
When to Refer
Steps to CKD Patient Care
Kidney transplantation
Starting Dialysis in the ElderlyhellipOr Not
Ckd management
Case 1
Slide Number 67
Lab results
Slide Number 69
Hypertensive nephropathy with proteinuria
Slide Number 71
Case 2
Slide Number 73
Management of CKD in Diabetes
Case 3
Case 3
Systemic Lupus Erythematosus (SLE)
SLE ndash Lupus Nephritis
Case 5
Case 5
Slide Number 81
Slide Number 82
Case study
Slide Number 84
CXR ndash Hilar Lymphadenopathy
Whats needed next
Slide Number 87
newly dx ckd
Slide Number 89
Bibliography
bibliography
bibliography
bibliography
bibliography
Stage 12
Stage 3
Stage 4
Stage 5
Hb le10 gdL
52
56
11
272
Hb gt10-le12 gdL
216
359
426
483
Hb le12 gdL
267
416
536
755
Stage 12
Stage 3
Stage 4
Stage 5
GOALS OF CARE IN CKD GLUCOSE CONTROL
bull Target HbA1c ~70 (lt695 greatest chance of reducing albuminuria)bull Can be extended above 70 with comorbidities or limited life expectancy and
risk of hypoglycemiabull Risk of hypoglycemia increases as kidney function becomes impairedbull Declining kidney function may necessitate changes to diabetes medications and
bull Just having HTN can cause proteinuriabull Usually 1-2 gms of protein a daybull Treat them like a diabetic with ACEI or ARBS and tight blood
pressure controlbull JNC-8 goal lt14090 for ptrsquos with CKDbull National kidney foundation lt14090 if ckd and no proteinuria
lt13080 if proteinuria present
(James Ortiz amp Et Al 2014)
TREATING HYPERTENSIONPROTEINURIA ACEI ORARBbull Riskbenefit should be carefully assessed in the elderly and medically fragilebull Check labs after initiation
bull If less than 30 SCr increase continue and monitorbull If more than 30 SCr increase stop ACEi and evaluate for renal artery stenosis
bull Continue until contraindication arises no absolute eGFR cutoffbull Better proteinuria suppression with low Na diet and diureticsbull Avoid volume depletionbull Avoid ACEi and ARB in combination12
bull Risk of adverse events (impaired kidney function hyperkalemia)
(Kunz Friedrich Wolbers amp Mann 2008)(Mann Schmieder amp McQueen 2008)
bull In adults gt50 yrs statin when eGFR ge 60 mlmin173m2 statin or statinezetimibe combination when eGFR lt 60 mlmin173m2
bull In adults lt 50 yrs statin if history of known CAD MI DM strokebull Aspirin is indicated for secondary but not primary prevention
Kidney Disease Improving Global Outcomes (KDIGO) CKD Work Group Kidney Int Suppls 201331-150
STATINS-RENOPROTECTIVECONTROVERSY
bull HMG-CoA reductase inhibitors (statins) in high doses can cause proteinuria
bull Possibly associated with less inflammation endothelial dysfunction and scarring in the kidney because they also block inflammatory cytokines
bull Use statins for CV disease not to treat proteinuria
(Afzali and Goldsmith 2016)
MEDICINE CAUTION
bull Hold metformin when gfr lt35 mlmin
bull GFR lt50 mlmin should alert to check all doses of meds
bull No bisphosphanates lt35 mlmin
bull No NSAIDScox 2 inhibitors lt60 mlmin
bull Atenolol ndashrenal excretion
bull BACTRIM A lot of AKI
MEDICINE CAUTION
bull Lovenox-use subcut heparinbull Apixibanbull Dabigatranbull Rivaroxibanbull Lithiumbull GABAPENTIN (ckd 4 max 300mg qd ckd 5 max 300mg qod)
STEPS TO CKD PATIENT CARE
1 CKD definition and risks2 Assess GFR albuminuria3 Determine etiology4 Assess for evidence of progression5 Assess for associated complications6 Discuss dialysistransplantation
CKD-CVD-DIABETES LINK CKD IS A DISEASE MULTIPLIER
National kidney foundation 2014
KDIGO 2017
CKD-MINERAL BONE DISORDERS
bull As kidneys fail they
bull Stop activating calcitriol (the active form of Vit D)mdashcausing calcium imbalance
bull Do not remove phosphorus from bloodmdashleading to phosphorus retention
bull The extra phosphorus pulls calcium out of bones causing them to weaken
bull High phosphorus stimulates PTH release
bull These changes (plus others) cause the start of secondary hyperparathyroidism
bull Labs
bull eGFR
bull Calcium
bull Phos
bull Vit D
bull iPTH
(Qunibi amp Henrich 2017)
PREVALENCE OF ABNORMALITIES OF MINERAL METABOLISM PTH IN CKD
bull Progression of disease ndash declining eGFR increasing proteinuria
bull Degree of proteinuria nephrotic syndrome gt 05-10 gd on ACEi or ARB therapy
bull Etiology of CKD not certain
bull Need help with disease management
bull Indications for kidney biopsy
Rosenberg 2016
WHEN TO REFER
STEPS TO CKD PATIENT CARE
1 CKD definition and risks2 Assess GFR albuminuria3 Determine etiology4 Assess for evidence of progression5 Assess for associated complications6 Discuss dialysistransplantation
KIDNEY TRANSPLANTATION
bull Treatment of choice for ESRDbull Improves quality of lifebull Waiting list time varies-3-5 yearsbull 3 year survival rate after transplantation is 83-94bull Increased risk of cancer
STARTING DIALYSIS IN THE ELDERLYhellipOR NOT
bull Among patients gt 75 yrs with stage 5 CKD who chose to NOT start dialysisbull Overall more likely to die over next 1-2 years bull But if they had ischemic heart disease or other significant comorbidity NO
DIFFERENCE in survival
bull Active disease management and supportive care may be appropriate without starting dialysis in the ill elderly
bull Palliative care does not mean ldquono carerdquo
bull Must have end-of-life discussions
(Murtagh et al 2007)
CKD MANAGEMENTbull Diagnose cause and treat underlying conditionbull Stage per guidelinesbull Slow progression of kidney disease (ACE inhibitors)bull Monitor for complicationsmdashvolume overload hyperkalemia metabolic acidosis
hyperphosphatemia anorexia fatigue htn bone diseasebull Labs cmp cbc phos Vit D 25OH iPTH urine microscopy uric acid urine
proteincr ratio-frequency based off heat map Get sono at least oncebull Vaccinate influenza hep B pneumococcalbull Eval ASCVD risk-likely needs statinbull Possible dexa (donrsquot give bisphosphonates if GFRlt35 let specialist manage)bull Refer to nephrology when eGFR is lt30 (sometimes if higher risk-refer earlier)
CASE 1
bull 55 year old man with past medical history of headaches presents to your office for his first time visit to a PCP in over 30 years
bull He has no past history of being admitted to the hospital and he does not take any OTC medsNSAIDsherbal meds He has no history of ETOH abuse smoking or drug use
bull Vitals BP 180100 mmHg pulse 80 R 18
bull Exam No JVD S1S2 regular PMI shifted to the left no gallop no abdominal bruit pulses bilaterally equal and regular no leg edema
bull What would you order
bull EKG cbc cmp ua urine proteincr ratio lipid
LAB RESULTS
bull Labs reveal a creatinine of 22 mgdL eGFR 33 Urine shows no blood or casts Urineprotein ratio shows 1 gm protein24 hrs EKG shows LVH
bull Next step in workupbull Renal ultrasound 1st then SPEP UPEP with immunofixation serum free light chains
bull Additional labs neg Renal ultrasound shows that both kidneys are slightly reduced in size and are mildly echogenic with no mass or hydronephrosis
bull What is your diagnosis
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileMain_complications_of_persistent_high_blood_pressurepngCreative Commons License associated httpcreativecommonsorglicensesby-sa30
bull 3 months Howevermdashwe have evidence of structural abnormalities Could potentially stage at G3b A3 (red on the heat map)
bull Goal blood pressure
bull JNC 8 14090 NKF 13080
bull Additional lab needed for progression monitoring
bull Cbc renal panel phos Vit D iPTH uric acid urine micro (we already have the renal sono and urine proteincr ratio and lipid)
Selective renal angiography (left lower renal artery) after successful percutaneous balloon dilatation of the stenotic lesionFibromuscular dysplasia in an accessory renal artery causing renovascular hypertension
Secondary Hypertension
Images retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileRenal_FMD2jpg and httpcommonswikimediaorgwikiFileRenal_FMDjpgCreative Commons License associated httpcreativecommonsorglicensesby20deeden (both images)
CASE 2bull OS is a 64year old Hispanic female in for DM check She has had DM for 15+ years and is currently
taking metformin 1000mg bid Lisinopril 10mg a day atorvastatin 40mg a day Labs today showed the following
bull Hgba1c 86 cmp eGFR 50 lipid WNL proteincr ratio 650mg These results are similar to her last visit
bull Upon further hx-you find that she had a recent eye exam and has mild nonproliferaive retinopathy She does not have neuropathy or other ss
bull What further workup do you need
bull Renal sonogram urine micro iPTH vit D (25 OH) phos uric acid
bull Dx stage
bull G3a A3
bull What further treatment do you need
bull Improve glycemic control Increase Lisinopril to 20mg with a goal of 40mg Avoid NSAIDs or other nephrotoxic agents make sure meds are renally dosed monitor 3xyear nephro referral
MANAGEMENT OF CKD IN DIABETESeGFR Recommended
All patients
Yearly measurement of creatinine urinary albumin excretion potassium
45-60 Referral to a nephrologist if possibility for nondiabetickidney disease existsConsider dose adjustment of medicationsMonitor eGFR every 6 monthsMonitor electrolytes bicarbonate hemoglobin calcium phosphorus parathyroid hormone at least yearly
Assure vitamin D sufficiencyConsider bone density testingReferral for dietary counselling
American Diabetes Association Standards of Medical Care in Diabetes Microvascular complications and foot care Diabetes Care 2017 40 (Suppl 1) S88-S98
CASE 3
bull 19 year old African American woman presents to your clinic with complaints of fatigue joint pains a new rash on her face oral ulcer
bull On exam BP 15080 P 88 Afebrile 96 O2 sats on RAbull GEN No respiratory distress at restbull HEENT painless oral ulcer flat rash over malar eminences sparing the nasolabial fold pallor +bull Lungs CTAbull CVS S1S2 regularbull Abdomen soft NTbull Ext left elbow joint and bilateral wrist joints are swollen and tender
bull What would you orderbull CBC CMP ua urine microscopy (microalbumin or urine proteincr ratio) ANA esr RF anti-ccp uric acid TSH
CASE 3
bull Working dx fatigue oral ulcer joint pain
bull Basic Labs Na 135 K 55 Bicarb 18 BUN 50 Cr 35 eGFR 22 Ca 90 ANA + titer 1640
bull UA 3+ blood 3+ protein RBC casts +
bull Given these results what is the most likely diagnosis
bull What would you do
SYSTEMIC LUPUS ERYTHEMATOSUS (SLE)
bull SLE multisystemic disease Etiology unknown
bull Production of autoantibodies and immune complexes formation
bull There is renal involvement in the great majority of patients with SLE at some time of the evolution 66-90
SLE ndash LUPUS NEPHRITIS
bull Race SLE is more commonsevere in African americans than Caucasiansbull
bull Gender female-to-male ratio of 91
bull Age Most patients develop lupus nephritis early in their disease course SLE is more common among women in the third decade of life and lupus nephritis occurs in patients aged 20-40 years
bull Kidney Biopsy For staging lupus nephritis (Class 1-5)
CASE 5bull A 80 year old man who has not seen a PCP in many years
presents to your clinic for weakness for the past few months On further questioning he tells you that his bones also have been hurting lately and he has developed leg swelling in the past month or so
bull On exam bull BP 16090 P 88 Afebrilebull GEN Thin built manbull HEENT pallor presentbull Lungs clearbull CVS S1S2 regular no rub or gallopbull Abdomen soft NTbull Ext 2 + edema
CASE 5
bull Differentials
bull CHF MI Cancer arthritis
bull Labs
bull CBC CMP urine microscopy urine proteincr ratio ESR TSH EKG BNP pa and lat CXR
bull LABS Urine dipstick negative for protein or blood
bull Basic chem bull Na 136 (135-145) K 51 (35-55) Chloride 108 (96-106) Bicarb 25
Given this presentation and the labs (low anion gap and elevated calcium anemia kidney failure) what will you think of What will you order next
Serum and urine protein electrophoresis
Intratubular refractile casts with surrounding syncytial giant cell reaction with chronic tubulointerstitial nephritis and fibrosis characteristic of myeloma cast nephropathy
Kidney Biopsy
CASE STUDYbull A 35 year old African American woman was seen in the clinic for
chronic cough and dyspnea on exertion She gave history of vague symptoms of fatigue and weight loss of 20 Ibs over the last six months
bull List some differentialsbull TB sarcoid lupus thyroid problems PEbull What would you orderbull PPD cbc cmp UA TSH ANA pa and lat cxr
bull Her labs were significant for mildly elevated calcium level and a creatinine of 20 mgdL eGFR 37
bull She had 750 mg of proteinuriaday
bull PPD neg ANA neg TSH and other labs WNL
bull Assuming this is present more than 3 monthshelliphellipwhat is her ckd stage
bull G3b A3
bull What do we still need
CT scan of chest
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileAnterior_mediastinal_mass_thymomajpgCreative Commons License associated httpcreativecommonsorglicensesby20deeden
CXR ndash HILAR LYMPHADENOPATHY
WHATS NEEDED NEXT
bull Biopsy of hilar lymphadenopathy or renal biopsy
bull DX sarcoidosis
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileSarcoidosis_signs_and_symptomsjpgThis work is in the public domain in the United States because it is a work of the United States Federal Government under the terms of Title 17 Chapter 1 Section 105 of the US Code
NEWLY DX CKD
bull 1) urinalysis microscopy ultrasound proteincr ratio
bull If obstruction-treat
bull No obstruction
bull Hx critical (consider myeloma if high risk)
bull glomerular bleeding or albumin in urine
bull Yes workup for glomerular causes (ANArf hep B C upep spep ANCA complement C3 C4)
bull No sterile pyruria-consider interstitial nephritis
bull High risk renovascular disease Evaluate renovascular disease
Additional Online Resources for CKD LearningbullNational Kidney Foundation wwwkidneyorgbullUnited States Renal Data Service wwwusrdsorgbullCDCrsquos CKD Surveillance Project
httpnccdcdcgovckdbullNational Kidney Disease Education Program
(NKDEP) httpnkdepnihgov
BIBLIOGRAPHY
bull Afzali B amp Goldsmith D J (2016 June 29) Statins and chronic kidney disease (G C Curhan amp A M Sheridan Eds) Retrieved 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsstatins-and-chronic-kidney-disease
bull American Diabetes Association Standards of Medical Care in Diabetes (2017) Microvascular complications and foot care Diabetes Care 2017 (40) S88-S98
bull American Diabetes Association Standards of Medical Care in Diabetes (2017) Microvascular complications and foot care Diabetes Care 40 (suppl 1) S88-S98
bull Berns J S (2017 Mar 22) Treatment of anemia in nondialysis chronic kidney disease (T A Golper amp A M Sheridan Eds) Retrieved from UpToDate httpswww-uptodate-comproxywichitaeducontentstreatment-of-anemia-in-nondialysis-chronic-kidney-disease
bull Chan M Dall A T Fletcher K E Lu N amp Trivedi H (2007) Outcomes in patients with chronic kidney disease referred late to nephrologists a meta-analysis American Journal of Medicine 120(12) 1063-1070
bull Coresh J Selvin E amp Stevens L A (2007) Prevalence of chronic kidny disease in the United States JAMA 298(17) doi101001jama298172038
bull de Brito-Ashurst I Varagunam M Raftery M amp Yagoob M (2009) Bicarbonate supplementation slows progression of CKD and improves nutritional status Journal of American Society of Nephrology (20) 2075-2084
BIBLIOGRAPHY
bull Duncan L Heathcoat J Djurdjev O amp Levin A (2001) Screening for renal disease using serum creatinine who are we missing Nephrology Dialysis and Transplant 16(5) 1042-1046
bull Dunkler D Gao P Lee S F Heinz G Clase C M Tobe S Oberbauer R (2015 August 7) Risk prediction for early CKD in type 2 diabetes Retrieved from Clinical Journal of the American Society of Nephrology httpcjasnasnjournalsorgcontent1081371fullsid=61422554-a5f1-41ac-b696-dcd3b12bd268
bull Fatehi P amp Chi-yuan H (September 15 2016) Diagnostic approach to the patient with newly identified chronic kidney disease (G C Curhan amp A M Sheridan Eds) Retrieved May 7 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsdiagnostic-approach-to-the-patient-with-newly-identified-chronic-kidney-disease
bull Fink J e (2009) Chronic Kidney Disease as an Under-Recognized Threat to Patient Safety American journal of kidney diseases the official journal of the National Kidney Foundation 53(4) 681-688
bull Gaffo A L amp Saag K G (2008 Nov) Management of hyperuricemia and gout in CKD doihttpdxdoiorg101053jajkd200807035
bull Hebert L A amp Parikh S V (2014 June 18) Differential diagnosis and evaluation of glomerular disease (R J Glassock amp A Q Lam Eds) Retrieved May 7 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsdifferential-diagnosis-and-evaluation-of-glomerular-disease
bull Inker L Perrone R D Sterns R H amp Forman J P (2017 March 7) Assessment of kidney function Retrieved from UpToDate httpswww-uptodate-comproxywichitaeducontentsassessment-of-kidney-functionsource=search_resultampsearch=creatinineampselectedTitle=1~150
BIBLIOGRAPHY
bull James P A Ortiz E amp Et Al (2014) Evidence based guideline for the management of high blood pressure in adults (JNC) JAMA 311(5) 507-520
bull Kidney Disease Improving Global Outcomes (KDIGO) CKD Work Group (2013 January) KDIGO 2012 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease Retrieved from Kidney International Supplement httpwwwkidney-internationalorg
bull Kunz R Friedrich C Wolbers M amp Mann J F (2008) Meta-analysis effect of monotherapy and combination therapy with inhibitors of the renin angiotensin system on proteinuria in renal disease Annals of Internal Medicine 148(1) 30-48
bull Levey A Stevens L A Schmid C H Castro A F Feldman H I Kusek J W Coresh J (2009) A new equation to estimate glomerular filtration rate Annals of Internal Medicine 150(9) 604-612
bull Levin A Bakris G L Molitch M Smulders M M Williams L A amp Andress D L (2007 Jan) Prevalence of abnormal serum vitamin D PTH calcium and phosphorus in patients with chronic kidney disease results of the study to evaluate early kidney disease Kidney International 71(1) 31-38 Retrieved from PubMED
bull Mahajan A Simoni J Sheather S Broglio K Rajab M amp Wesson D (2010) Daily oral sodium bicarbonate preserves glomerular filtration rate by slowing its decline in early hypertensive nephropathy Kidney International (78_ 303-309
bull Mann J Schmieder R E amp McQueen M (2008) Renal outcomes with telmisartan ramipril or both in people at high vascular risk (the ONTARGET study) a multicentre randomised doubleblind ocntrolled trial Lancet 372(9638) 547-533
BIBLIOGRAPHY
bull Matovinović M S (2009) Pathophysiology and classification of kidney disease Retrieved from The Journal of the International Federation of Clinical Chemistry and Laboratory Medicine httpwwwifccorgifccfilesdocs20010902pdf
bull Moe S Drueke T Lameire N amp Eknoyan G (2007 Jan) Chronic kidney disease-mineral-bone disorder a new paradigmdoi101053jackd200610005
bull Murtagh F E Marsh J E Donohoe P Ekbal N J Sheerin N S amp Harris F E (2007 July) Dialysis or not A comparative survival study of patients over 75 years with chronic kidney disease stage 5 Retrieved from Nephrology Dialysis and Transplant 22(7) httpswwwncbinlmnihgovpubmed17412702
bull National Kidney Foundation (2002) KDOQI clinical practice guidelines for chronic kidney disease evaluation classification andstratification American Journal of Kidney Disease S1-S266
bull National Kidney Foundation (2014 November 5) Fact Sheets Retrieved from httpwwwkidneyorgnewsnewsroomfactsheetsFastFacts
bull Pal S (2012 June 2) Trends in chronic kidney disease Retrieved from US Pharmacist (37)6 httpswwwuspharmacistcomarticletrends-in-chronic-kidney-disease
bull Qunibi W amp Henrich W L (2017 Jan 19) Overview of chronic kidney disease-mineral and bone disorder (J Berns amp A M Sheridan Eds) Retrieved from UpToDate httpswww-uptodate-comoverview-of-chronic-kidney-disease-mineral-and-bone-disorder-ckd-mbd
bull Rosenberg M (2016 Feb 24) Overview of the management of chronic kidney disease in adults (G C Curhan amp A M Sheridan Eds) Retrieved from UpToDate UpToDate httpswww-uptodate-comproxywichitaeducontentsoverview-of-the-management-of-chronic-kidney-disease-in-adults
BIBLIOGRAPHY
bull Szczech L Stewart R C Hsu-Lin S DeLosky R J Astor B C Fox C H Vassalotti J A (2014) Primary care detection of chronic kidney disease in adults with type 2 diabetes The ADD-CKD Study (Awareness Detection and Drug Therapy in type 2 diabetes and chronic kidney disease PLOS doihttpsdoiorg101371journalpone0110535
bull USRDS (2016) Annual data report 2016 Epidemiology of kidney disease in the United States Retrieved from United States Renal Data System httpswwwusrdsorgadraspx
bull Vasudev B amp Vasudev M (2012) A model curriculum for residents rotating in nephrology MedEDPORTAL doihttpdoiorg1015766mep_2374-82658288
bull Wei L MacDonald T M Jennings C Sheng X amp Flynn R W (2013) Estimated GFR reporting is associated with decreased nonsteroidal anti-inflammatory drug prescribing and increased renal function Kidney International (84)1 174-178
chronic kidney disease in primary care
CKD as a Public Health Issue
Slide Number 3
Costs of CKD in 2013 dollarsUSRDS report
Steps to CKD Patient Care
Renal anatomy and physiology
Definition of Chronic Kidney Disease
CKD Risk Factors
Gaps in CKD Diagnosis
Slide Number 10
Steps to CKD Patient Care
creatinine
Glomerular filtration rate
Slide Number 14
Slide Number 15
Use These Equations Cautiously if at all in hellip
lab albumin creatinine ratio
The New CKD Categories
Steps to CKD Patient Care
Slide Number 20
Kidney Involvement in Systemic Diseases
Slide Number 22
Slide Number 23
DysmorphicRenal Hematuria
Slide Number 25
If you have albuminuria or hematuria-order the following labs
Prevalence of Abnormalities of Mineral Metabolism PTH in CKD
Managing CKD-MBD complications
CKD-MBD Testing
Anemia Becomes More Common as Kidney Function Declines
Detect and Manage CKD Complications
Complications-metabolic acidosis
Complications-vascular calcification
Hyperkalemia management
Hyperuricemia levels amp CKD
CKD monitoring levels 345
Slide Number 59
When to Refer to a Nephrologist
When to Refer
Steps to CKD Patient Care
Kidney transplantation
Starting Dialysis in the ElderlyhellipOr Not
Ckd management
Case 1
Slide Number 67
Lab results
Slide Number 69
Hypertensive nephropathy with proteinuria
Slide Number 71
Case 2
Slide Number 73
Management of CKD in Diabetes
Case 3
Case 3
Systemic Lupus Erythematosus (SLE)
SLE ndash Lupus Nephritis
Case 5
Case 5
Slide Number 81
Slide Number 82
Case study
Slide Number 84
CXR ndash Hilar Lymphadenopathy
Whats needed next
Slide Number 87
newly dx ckd
Slide Number 89
Bibliography
bibliography
bibliography
bibliography
bibliography
Stage 12
Stage 3
Stage 4
Stage 5
Hb le10 gdL
52
56
11
272
Hb gt10-le12 gdL
216
359
426
483
Hb le12 gdL
267
416
536
755
Stage 12
Stage 3
Stage 4
Stage 5
HYPERTENSION 2 CAUSE OF CKD
bull Just having HTN can cause proteinuriabull Usually 1-2 gms of protein a daybull Treat them like a diabetic with ACEI or ARBS and tight blood
pressure controlbull JNC-8 goal lt14090 for ptrsquos with CKDbull National kidney foundation lt14090 if ckd and no proteinuria
lt13080 if proteinuria present
(James Ortiz amp Et Al 2014)
TREATING HYPERTENSIONPROTEINURIA ACEI ORARBbull Riskbenefit should be carefully assessed in the elderly and medically fragilebull Check labs after initiation
bull If less than 30 SCr increase continue and monitorbull If more than 30 SCr increase stop ACEi and evaluate for renal artery stenosis
bull Continue until contraindication arises no absolute eGFR cutoffbull Better proteinuria suppression with low Na diet and diureticsbull Avoid volume depletionbull Avoid ACEi and ARB in combination12
bull Risk of adverse events (impaired kidney function hyperkalemia)
(Kunz Friedrich Wolbers amp Mann 2008)(Mann Schmieder amp McQueen 2008)
bull In adults gt50 yrs statin when eGFR ge 60 mlmin173m2 statin or statinezetimibe combination when eGFR lt 60 mlmin173m2
bull In adults lt 50 yrs statin if history of known CAD MI DM strokebull Aspirin is indicated for secondary but not primary prevention
Kidney Disease Improving Global Outcomes (KDIGO) CKD Work Group Kidney Int Suppls 201331-150
STATINS-RENOPROTECTIVECONTROVERSY
bull HMG-CoA reductase inhibitors (statins) in high doses can cause proteinuria
bull Possibly associated with less inflammation endothelial dysfunction and scarring in the kidney because they also block inflammatory cytokines
bull Use statins for CV disease not to treat proteinuria
(Afzali and Goldsmith 2016)
MEDICINE CAUTION
bull Hold metformin when gfr lt35 mlmin
bull GFR lt50 mlmin should alert to check all doses of meds
bull No bisphosphanates lt35 mlmin
bull No NSAIDScox 2 inhibitors lt60 mlmin
bull Atenolol ndashrenal excretion
bull BACTRIM A lot of AKI
MEDICINE CAUTION
bull Lovenox-use subcut heparinbull Apixibanbull Dabigatranbull Rivaroxibanbull Lithiumbull GABAPENTIN (ckd 4 max 300mg qd ckd 5 max 300mg qod)
STEPS TO CKD PATIENT CARE
1 CKD definition and risks2 Assess GFR albuminuria3 Determine etiology4 Assess for evidence of progression5 Assess for associated complications6 Discuss dialysistransplantation
CKD-CVD-DIABETES LINK CKD IS A DISEASE MULTIPLIER
National kidney foundation 2014
KDIGO 2017
CKD-MINERAL BONE DISORDERS
bull As kidneys fail they
bull Stop activating calcitriol (the active form of Vit D)mdashcausing calcium imbalance
bull Do not remove phosphorus from bloodmdashleading to phosphorus retention
bull The extra phosphorus pulls calcium out of bones causing them to weaken
bull High phosphorus stimulates PTH release
bull These changes (plus others) cause the start of secondary hyperparathyroidism
bull Labs
bull eGFR
bull Calcium
bull Phos
bull Vit D
bull iPTH
(Qunibi amp Henrich 2017)
PREVALENCE OF ABNORMALITIES OF MINERAL METABOLISM PTH IN CKD
bull Progression of disease ndash declining eGFR increasing proteinuria
bull Degree of proteinuria nephrotic syndrome gt 05-10 gd on ACEi or ARB therapy
bull Etiology of CKD not certain
bull Need help with disease management
bull Indications for kidney biopsy
Rosenberg 2016
WHEN TO REFER
STEPS TO CKD PATIENT CARE
1 CKD definition and risks2 Assess GFR albuminuria3 Determine etiology4 Assess for evidence of progression5 Assess for associated complications6 Discuss dialysistransplantation
KIDNEY TRANSPLANTATION
bull Treatment of choice for ESRDbull Improves quality of lifebull Waiting list time varies-3-5 yearsbull 3 year survival rate after transplantation is 83-94bull Increased risk of cancer
STARTING DIALYSIS IN THE ELDERLYhellipOR NOT
bull Among patients gt 75 yrs with stage 5 CKD who chose to NOT start dialysisbull Overall more likely to die over next 1-2 years bull But if they had ischemic heart disease or other significant comorbidity NO
DIFFERENCE in survival
bull Active disease management and supportive care may be appropriate without starting dialysis in the ill elderly
bull Palliative care does not mean ldquono carerdquo
bull Must have end-of-life discussions
(Murtagh et al 2007)
CKD MANAGEMENTbull Diagnose cause and treat underlying conditionbull Stage per guidelinesbull Slow progression of kidney disease (ACE inhibitors)bull Monitor for complicationsmdashvolume overload hyperkalemia metabolic acidosis
hyperphosphatemia anorexia fatigue htn bone diseasebull Labs cmp cbc phos Vit D 25OH iPTH urine microscopy uric acid urine
proteincr ratio-frequency based off heat map Get sono at least oncebull Vaccinate influenza hep B pneumococcalbull Eval ASCVD risk-likely needs statinbull Possible dexa (donrsquot give bisphosphonates if GFRlt35 let specialist manage)bull Refer to nephrology when eGFR is lt30 (sometimes if higher risk-refer earlier)
CASE 1
bull 55 year old man with past medical history of headaches presents to your office for his first time visit to a PCP in over 30 years
bull He has no past history of being admitted to the hospital and he does not take any OTC medsNSAIDsherbal meds He has no history of ETOH abuse smoking or drug use
bull Vitals BP 180100 mmHg pulse 80 R 18
bull Exam No JVD S1S2 regular PMI shifted to the left no gallop no abdominal bruit pulses bilaterally equal and regular no leg edema
bull What would you order
bull EKG cbc cmp ua urine proteincr ratio lipid
LAB RESULTS
bull Labs reveal a creatinine of 22 mgdL eGFR 33 Urine shows no blood or casts Urineprotein ratio shows 1 gm protein24 hrs EKG shows LVH
bull Next step in workupbull Renal ultrasound 1st then SPEP UPEP with immunofixation serum free light chains
bull Additional labs neg Renal ultrasound shows that both kidneys are slightly reduced in size and are mildly echogenic with no mass or hydronephrosis
bull What is your diagnosis
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileMain_complications_of_persistent_high_blood_pressurepngCreative Commons License associated httpcreativecommonsorglicensesby-sa30
bull 3 months Howevermdashwe have evidence of structural abnormalities Could potentially stage at G3b A3 (red on the heat map)
bull Goal blood pressure
bull JNC 8 14090 NKF 13080
bull Additional lab needed for progression monitoring
bull Cbc renal panel phos Vit D iPTH uric acid urine micro (we already have the renal sono and urine proteincr ratio and lipid)
Selective renal angiography (left lower renal artery) after successful percutaneous balloon dilatation of the stenotic lesionFibromuscular dysplasia in an accessory renal artery causing renovascular hypertension
Secondary Hypertension
Images retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileRenal_FMD2jpg and httpcommonswikimediaorgwikiFileRenal_FMDjpgCreative Commons License associated httpcreativecommonsorglicensesby20deeden (both images)
CASE 2bull OS is a 64year old Hispanic female in for DM check She has had DM for 15+ years and is currently
taking metformin 1000mg bid Lisinopril 10mg a day atorvastatin 40mg a day Labs today showed the following
bull Hgba1c 86 cmp eGFR 50 lipid WNL proteincr ratio 650mg These results are similar to her last visit
bull Upon further hx-you find that she had a recent eye exam and has mild nonproliferaive retinopathy She does not have neuropathy or other ss
bull What further workup do you need
bull Renal sonogram urine micro iPTH vit D (25 OH) phos uric acid
bull Dx stage
bull G3a A3
bull What further treatment do you need
bull Improve glycemic control Increase Lisinopril to 20mg with a goal of 40mg Avoid NSAIDs or other nephrotoxic agents make sure meds are renally dosed monitor 3xyear nephro referral
MANAGEMENT OF CKD IN DIABETESeGFR Recommended
All patients
Yearly measurement of creatinine urinary albumin excretion potassium
45-60 Referral to a nephrologist if possibility for nondiabetickidney disease existsConsider dose adjustment of medicationsMonitor eGFR every 6 monthsMonitor electrolytes bicarbonate hemoglobin calcium phosphorus parathyroid hormone at least yearly
Assure vitamin D sufficiencyConsider bone density testingReferral for dietary counselling
American Diabetes Association Standards of Medical Care in Diabetes Microvascular complications and foot care Diabetes Care 2017 40 (Suppl 1) S88-S98
CASE 3
bull 19 year old African American woman presents to your clinic with complaints of fatigue joint pains a new rash on her face oral ulcer
bull On exam BP 15080 P 88 Afebrile 96 O2 sats on RAbull GEN No respiratory distress at restbull HEENT painless oral ulcer flat rash over malar eminences sparing the nasolabial fold pallor +bull Lungs CTAbull CVS S1S2 regularbull Abdomen soft NTbull Ext left elbow joint and bilateral wrist joints are swollen and tender
bull What would you orderbull CBC CMP ua urine microscopy (microalbumin or urine proteincr ratio) ANA esr RF anti-ccp uric acid TSH
CASE 3
bull Working dx fatigue oral ulcer joint pain
bull Basic Labs Na 135 K 55 Bicarb 18 BUN 50 Cr 35 eGFR 22 Ca 90 ANA + titer 1640
bull UA 3+ blood 3+ protein RBC casts +
bull Given these results what is the most likely diagnosis
bull What would you do
SYSTEMIC LUPUS ERYTHEMATOSUS (SLE)
bull SLE multisystemic disease Etiology unknown
bull Production of autoantibodies and immune complexes formation
bull There is renal involvement in the great majority of patients with SLE at some time of the evolution 66-90
SLE ndash LUPUS NEPHRITIS
bull Race SLE is more commonsevere in African americans than Caucasiansbull
bull Gender female-to-male ratio of 91
bull Age Most patients develop lupus nephritis early in their disease course SLE is more common among women in the third decade of life and lupus nephritis occurs in patients aged 20-40 years
bull Kidney Biopsy For staging lupus nephritis (Class 1-5)
CASE 5bull A 80 year old man who has not seen a PCP in many years
presents to your clinic for weakness for the past few months On further questioning he tells you that his bones also have been hurting lately and he has developed leg swelling in the past month or so
bull On exam bull BP 16090 P 88 Afebrilebull GEN Thin built manbull HEENT pallor presentbull Lungs clearbull CVS S1S2 regular no rub or gallopbull Abdomen soft NTbull Ext 2 + edema
CASE 5
bull Differentials
bull CHF MI Cancer arthritis
bull Labs
bull CBC CMP urine microscopy urine proteincr ratio ESR TSH EKG BNP pa and lat CXR
bull LABS Urine dipstick negative for protein or blood
bull Basic chem bull Na 136 (135-145) K 51 (35-55) Chloride 108 (96-106) Bicarb 25
Given this presentation and the labs (low anion gap and elevated calcium anemia kidney failure) what will you think of What will you order next
Serum and urine protein electrophoresis
Intratubular refractile casts with surrounding syncytial giant cell reaction with chronic tubulointerstitial nephritis and fibrosis characteristic of myeloma cast nephropathy
Kidney Biopsy
CASE STUDYbull A 35 year old African American woman was seen in the clinic for
chronic cough and dyspnea on exertion She gave history of vague symptoms of fatigue and weight loss of 20 Ibs over the last six months
bull List some differentialsbull TB sarcoid lupus thyroid problems PEbull What would you orderbull PPD cbc cmp UA TSH ANA pa and lat cxr
bull Her labs were significant for mildly elevated calcium level and a creatinine of 20 mgdL eGFR 37
bull She had 750 mg of proteinuriaday
bull PPD neg ANA neg TSH and other labs WNL
bull Assuming this is present more than 3 monthshelliphellipwhat is her ckd stage
bull G3b A3
bull What do we still need
CT scan of chest
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileAnterior_mediastinal_mass_thymomajpgCreative Commons License associated httpcreativecommonsorglicensesby20deeden
CXR ndash HILAR LYMPHADENOPATHY
WHATS NEEDED NEXT
bull Biopsy of hilar lymphadenopathy or renal biopsy
bull DX sarcoidosis
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileSarcoidosis_signs_and_symptomsjpgThis work is in the public domain in the United States because it is a work of the United States Federal Government under the terms of Title 17 Chapter 1 Section 105 of the US Code
NEWLY DX CKD
bull 1) urinalysis microscopy ultrasound proteincr ratio
bull If obstruction-treat
bull No obstruction
bull Hx critical (consider myeloma if high risk)
bull glomerular bleeding or albumin in urine
bull Yes workup for glomerular causes (ANArf hep B C upep spep ANCA complement C3 C4)
bull No sterile pyruria-consider interstitial nephritis
bull High risk renovascular disease Evaluate renovascular disease
Additional Online Resources for CKD LearningbullNational Kidney Foundation wwwkidneyorgbullUnited States Renal Data Service wwwusrdsorgbullCDCrsquos CKD Surveillance Project
httpnccdcdcgovckdbullNational Kidney Disease Education Program
(NKDEP) httpnkdepnihgov
BIBLIOGRAPHY
bull Afzali B amp Goldsmith D J (2016 June 29) Statins and chronic kidney disease (G C Curhan amp A M Sheridan Eds) Retrieved 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsstatins-and-chronic-kidney-disease
bull American Diabetes Association Standards of Medical Care in Diabetes (2017) Microvascular complications and foot care Diabetes Care 2017 (40) S88-S98
bull American Diabetes Association Standards of Medical Care in Diabetes (2017) Microvascular complications and foot care Diabetes Care 40 (suppl 1) S88-S98
bull Berns J S (2017 Mar 22) Treatment of anemia in nondialysis chronic kidney disease (T A Golper amp A M Sheridan Eds) Retrieved from UpToDate httpswww-uptodate-comproxywichitaeducontentstreatment-of-anemia-in-nondialysis-chronic-kidney-disease
bull Chan M Dall A T Fletcher K E Lu N amp Trivedi H (2007) Outcomes in patients with chronic kidney disease referred late to nephrologists a meta-analysis American Journal of Medicine 120(12) 1063-1070
bull Coresh J Selvin E amp Stevens L A (2007) Prevalence of chronic kidny disease in the United States JAMA 298(17) doi101001jama298172038
bull de Brito-Ashurst I Varagunam M Raftery M amp Yagoob M (2009) Bicarbonate supplementation slows progression of CKD and improves nutritional status Journal of American Society of Nephrology (20) 2075-2084
BIBLIOGRAPHY
bull Duncan L Heathcoat J Djurdjev O amp Levin A (2001) Screening for renal disease using serum creatinine who are we missing Nephrology Dialysis and Transplant 16(5) 1042-1046
bull Dunkler D Gao P Lee S F Heinz G Clase C M Tobe S Oberbauer R (2015 August 7) Risk prediction for early CKD in type 2 diabetes Retrieved from Clinical Journal of the American Society of Nephrology httpcjasnasnjournalsorgcontent1081371fullsid=61422554-a5f1-41ac-b696-dcd3b12bd268
bull Fatehi P amp Chi-yuan H (September 15 2016) Diagnostic approach to the patient with newly identified chronic kidney disease (G C Curhan amp A M Sheridan Eds) Retrieved May 7 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsdiagnostic-approach-to-the-patient-with-newly-identified-chronic-kidney-disease
bull Fink J e (2009) Chronic Kidney Disease as an Under-Recognized Threat to Patient Safety American journal of kidney diseases the official journal of the National Kidney Foundation 53(4) 681-688
bull Gaffo A L amp Saag K G (2008 Nov) Management of hyperuricemia and gout in CKD doihttpdxdoiorg101053jajkd200807035
bull Hebert L A amp Parikh S V (2014 June 18) Differential diagnosis and evaluation of glomerular disease (R J Glassock amp A Q Lam Eds) Retrieved May 7 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsdifferential-diagnosis-and-evaluation-of-glomerular-disease
bull Inker L Perrone R D Sterns R H amp Forman J P (2017 March 7) Assessment of kidney function Retrieved from UpToDate httpswww-uptodate-comproxywichitaeducontentsassessment-of-kidney-functionsource=search_resultampsearch=creatinineampselectedTitle=1~150
BIBLIOGRAPHY
bull James P A Ortiz E amp Et Al (2014) Evidence based guideline for the management of high blood pressure in adults (JNC) JAMA 311(5) 507-520
bull Kidney Disease Improving Global Outcomes (KDIGO) CKD Work Group (2013 January) KDIGO 2012 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease Retrieved from Kidney International Supplement httpwwwkidney-internationalorg
bull Kunz R Friedrich C Wolbers M amp Mann J F (2008) Meta-analysis effect of monotherapy and combination therapy with inhibitors of the renin angiotensin system on proteinuria in renal disease Annals of Internal Medicine 148(1) 30-48
bull Levey A Stevens L A Schmid C H Castro A F Feldman H I Kusek J W Coresh J (2009) A new equation to estimate glomerular filtration rate Annals of Internal Medicine 150(9) 604-612
bull Levin A Bakris G L Molitch M Smulders M M Williams L A amp Andress D L (2007 Jan) Prevalence of abnormal serum vitamin D PTH calcium and phosphorus in patients with chronic kidney disease results of the study to evaluate early kidney disease Kidney International 71(1) 31-38 Retrieved from PubMED
bull Mahajan A Simoni J Sheather S Broglio K Rajab M amp Wesson D (2010) Daily oral sodium bicarbonate preserves glomerular filtration rate by slowing its decline in early hypertensive nephropathy Kidney International (78_ 303-309
bull Mann J Schmieder R E amp McQueen M (2008) Renal outcomes with telmisartan ramipril or both in people at high vascular risk (the ONTARGET study) a multicentre randomised doubleblind ocntrolled trial Lancet 372(9638) 547-533
BIBLIOGRAPHY
bull Matovinović M S (2009) Pathophysiology and classification of kidney disease Retrieved from The Journal of the International Federation of Clinical Chemistry and Laboratory Medicine httpwwwifccorgifccfilesdocs20010902pdf
bull Moe S Drueke T Lameire N amp Eknoyan G (2007 Jan) Chronic kidney disease-mineral-bone disorder a new paradigmdoi101053jackd200610005
bull Murtagh F E Marsh J E Donohoe P Ekbal N J Sheerin N S amp Harris F E (2007 July) Dialysis or not A comparative survival study of patients over 75 years with chronic kidney disease stage 5 Retrieved from Nephrology Dialysis and Transplant 22(7) httpswwwncbinlmnihgovpubmed17412702
bull National Kidney Foundation (2002) KDOQI clinical practice guidelines for chronic kidney disease evaluation classification andstratification American Journal of Kidney Disease S1-S266
bull National Kidney Foundation (2014 November 5) Fact Sheets Retrieved from httpwwwkidneyorgnewsnewsroomfactsheetsFastFacts
bull Pal S (2012 June 2) Trends in chronic kidney disease Retrieved from US Pharmacist (37)6 httpswwwuspharmacistcomarticletrends-in-chronic-kidney-disease
bull Qunibi W amp Henrich W L (2017 Jan 19) Overview of chronic kidney disease-mineral and bone disorder (J Berns amp A M Sheridan Eds) Retrieved from UpToDate httpswww-uptodate-comoverview-of-chronic-kidney-disease-mineral-and-bone-disorder-ckd-mbd
bull Rosenberg M (2016 Feb 24) Overview of the management of chronic kidney disease in adults (G C Curhan amp A M Sheridan Eds) Retrieved from UpToDate UpToDate httpswww-uptodate-comproxywichitaeducontentsoverview-of-the-management-of-chronic-kidney-disease-in-adults
BIBLIOGRAPHY
bull Szczech L Stewart R C Hsu-Lin S DeLosky R J Astor B C Fox C H Vassalotti J A (2014) Primary care detection of chronic kidney disease in adults with type 2 diabetes The ADD-CKD Study (Awareness Detection and Drug Therapy in type 2 diabetes and chronic kidney disease PLOS doihttpsdoiorg101371journalpone0110535
bull USRDS (2016) Annual data report 2016 Epidemiology of kidney disease in the United States Retrieved from United States Renal Data System httpswwwusrdsorgadraspx
bull Vasudev B amp Vasudev M (2012) A model curriculum for residents rotating in nephrology MedEDPORTAL doihttpdoiorg1015766mep_2374-82658288
bull Wei L MacDonald T M Jennings C Sheng X amp Flynn R W (2013) Estimated GFR reporting is associated with decreased nonsteroidal anti-inflammatory drug prescribing and increased renal function Kidney International (84)1 174-178
chronic kidney disease in primary care
CKD as a Public Health Issue
Slide Number 3
Costs of CKD in 2013 dollarsUSRDS report
Steps to CKD Patient Care
Renal anatomy and physiology
Definition of Chronic Kidney Disease
CKD Risk Factors
Gaps in CKD Diagnosis
Slide Number 10
Steps to CKD Patient Care
creatinine
Glomerular filtration rate
Slide Number 14
Slide Number 15
Use These Equations Cautiously if at all in hellip
lab albumin creatinine ratio
The New CKD Categories
Steps to CKD Patient Care
Slide Number 20
Kidney Involvement in Systemic Diseases
Slide Number 22
Slide Number 23
DysmorphicRenal Hematuria
Slide Number 25
If you have albuminuria or hematuria-order the following labs
Prevalence of Abnormalities of Mineral Metabolism PTH in CKD
Managing CKD-MBD complications
CKD-MBD Testing
Anemia Becomes More Common as Kidney Function Declines
Detect and Manage CKD Complications
Complications-metabolic acidosis
Complications-vascular calcification
Hyperkalemia management
Hyperuricemia levels amp CKD
CKD monitoring levels 345
Slide Number 59
When to Refer to a Nephrologist
When to Refer
Steps to CKD Patient Care
Kidney transplantation
Starting Dialysis in the ElderlyhellipOr Not
Ckd management
Case 1
Slide Number 67
Lab results
Slide Number 69
Hypertensive nephropathy with proteinuria
Slide Number 71
Case 2
Slide Number 73
Management of CKD in Diabetes
Case 3
Case 3
Systemic Lupus Erythematosus (SLE)
SLE ndash Lupus Nephritis
Case 5
Case 5
Slide Number 81
Slide Number 82
Case study
Slide Number 84
CXR ndash Hilar Lymphadenopathy
Whats needed next
Slide Number 87
newly dx ckd
Slide Number 89
Bibliography
bibliography
bibliography
bibliography
bibliography
Stage 12
Stage 3
Stage 4
Stage 5
Hb le10 gdL
52
56
11
272
Hb gt10-le12 gdL
216
359
426
483
Hb le12 gdL
267
416
536
755
Stage 12
Stage 3
Stage 4
Stage 5
TREATING HYPERTENSIONPROTEINURIA ACEI ORARBbull Riskbenefit should be carefully assessed in the elderly and medically fragilebull Check labs after initiation
bull If less than 30 SCr increase continue and monitorbull If more than 30 SCr increase stop ACEi and evaluate for renal artery stenosis
bull Continue until contraindication arises no absolute eGFR cutoffbull Better proteinuria suppression with low Na diet and diureticsbull Avoid volume depletionbull Avoid ACEi and ARB in combination12
bull Risk of adverse events (impaired kidney function hyperkalemia)
(Kunz Friedrich Wolbers amp Mann 2008)(Mann Schmieder amp McQueen 2008)
bull In adults gt50 yrs statin when eGFR ge 60 mlmin173m2 statin or statinezetimibe combination when eGFR lt 60 mlmin173m2
bull In adults lt 50 yrs statin if history of known CAD MI DM strokebull Aspirin is indicated for secondary but not primary prevention
Kidney Disease Improving Global Outcomes (KDIGO) CKD Work Group Kidney Int Suppls 201331-150
STATINS-RENOPROTECTIVECONTROVERSY
bull HMG-CoA reductase inhibitors (statins) in high doses can cause proteinuria
bull Possibly associated with less inflammation endothelial dysfunction and scarring in the kidney because they also block inflammatory cytokines
bull Use statins for CV disease not to treat proteinuria
(Afzali and Goldsmith 2016)
MEDICINE CAUTION
bull Hold metformin when gfr lt35 mlmin
bull GFR lt50 mlmin should alert to check all doses of meds
bull No bisphosphanates lt35 mlmin
bull No NSAIDScox 2 inhibitors lt60 mlmin
bull Atenolol ndashrenal excretion
bull BACTRIM A lot of AKI
MEDICINE CAUTION
bull Lovenox-use subcut heparinbull Apixibanbull Dabigatranbull Rivaroxibanbull Lithiumbull GABAPENTIN (ckd 4 max 300mg qd ckd 5 max 300mg qod)
STEPS TO CKD PATIENT CARE
1 CKD definition and risks2 Assess GFR albuminuria3 Determine etiology4 Assess for evidence of progression5 Assess for associated complications6 Discuss dialysistransplantation
CKD-CVD-DIABETES LINK CKD IS A DISEASE MULTIPLIER
National kidney foundation 2014
KDIGO 2017
CKD-MINERAL BONE DISORDERS
bull As kidneys fail they
bull Stop activating calcitriol (the active form of Vit D)mdashcausing calcium imbalance
bull Do not remove phosphorus from bloodmdashleading to phosphorus retention
bull The extra phosphorus pulls calcium out of bones causing them to weaken
bull High phosphorus stimulates PTH release
bull These changes (plus others) cause the start of secondary hyperparathyroidism
bull Labs
bull eGFR
bull Calcium
bull Phos
bull Vit D
bull iPTH
(Qunibi amp Henrich 2017)
PREVALENCE OF ABNORMALITIES OF MINERAL METABOLISM PTH IN CKD
bull Progression of disease ndash declining eGFR increasing proteinuria
bull Degree of proteinuria nephrotic syndrome gt 05-10 gd on ACEi or ARB therapy
bull Etiology of CKD not certain
bull Need help with disease management
bull Indications for kidney biopsy
Rosenberg 2016
WHEN TO REFER
STEPS TO CKD PATIENT CARE
1 CKD definition and risks2 Assess GFR albuminuria3 Determine etiology4 Assess for evidence of progression5 Assess for associated complications6 Discuss dialysistransplantation
KIDNEY TRANSPLANTATION
bull Treatment of choice for ESRDbull Improves quality of lifebull Waiting list time varies-3-5 yearsbull 3 year survival rate after transplantation is 83-94bull Increased risk of cancer
STARTING DIALYSIS IN THE ELDERLYhellipOR NOT
bull Among patients gt 75 yrs with stage 5 CKD who chose to NOT start dialysisbull Overall more likely to die over next 1-2 years bull But if they had ischemic heart disease or other significant comorbidity NO
DIFFERENCE in survival
bull Active disease management and supportive care may be appropriate without starting dialysis in the ill elderly
bull Palliative care does not mean ldquono carerdquo
bull Must have end-of-life discussions
(Murtagh et al 2007)
CKD MANAGEMENTbull Diagnose cause and treat underlying conditionbull Stage per guidelinesbull Slow progression of kidney disease (ACE inhibitors)bull Monitor for complicationsmdashvolume overload hyperkalemia metabolic acidosis
hyperphosphatemia anorexia fatigue htn bone diseasebull Labs cmp cbc phos Vit D 25OH iPTH urine microscopy uric acid urine
proteincr ratio-frequency based off heat map Get sono at least oncebull Vaccinate influenza hep B pneumococcalbull Eval ASCVD risk-likely needs statinbull Possible dexa (donrsquot give bisphosphonates if GFRlt35 let specialist manage)bull Refer to nephrology when eGFR is lt30 (sometimes if higher risk-refer earlier)
CASE 1
bull 55 year old man with past medical history of headaches presents to your office for his first time visit to a PCP in over 30 years
bull He has no past history of being admitted to the hospital and he does not take any OTC medsNSAIDsherbal meds He has no history of ETOH abuse smoking or drug use
bull Vitals BP 180100 mmHg pulse 80 R 18
bull Exam No JVD S1S2 regular PMI shifted to the left no gallop no abdominal bruit pulses bilaterally equal and regular no leg edema
bull What would you order
bull EKG cbc cmp ua urine proteincr ratio lipid
LAB RESULTS
bull Labs reveal a creatinine of 22 mgdL eGFR 33 Urine shows no blood or casts Urineprotein ratio shows 1 gm protein24 hrs EKG shows LVH
bull Next step in workupbull Renal ultrasound 1st then SPEP UPEP with immunofixation serum free light chains
bull Additional labs neg Renal ultrasound shows that both kidneys are slightly reduced in size and are mildly echogenic with no mass or hydronephrosis
bull What is your diagnosis
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileMain_complications_of_persistent_high_blood_pressurepngCreative Commons License associated httpcreativecommonsorglicensesby-sa30
bull 3 months Howevermdashwe have evidence of structural abnormalities Could potentially stage at G3b A3 (red on the heat map)
bull Goal blood pressure
bull JNC 8 14090 NKF 13080
bull Additional lab needed for progression monitoring
bull Cbc renal panel phos Vit D iPTH uric acid urine micro (we already have the renal sono and urine proteincr ratio and lipid)
Selective renal angiography (left lower renal artery) after successful percutaneous balloon dilatation of the stenotic lesionFibromuscular dysplasia in an accessory renal artery causing renovascular hypertension
Secondary Hypertension
Images retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileRenal_FMD2jpg and httpcommonswikimediaorgwikiFileRenal_FMDjpgCreative Commons License associated httpcreativecommonsorglicensesby20deeden (both images)
CASE 2bull OS is a 64year old Hispanic female in for DM check She has had DM for 15+ years and is currently
taking metformin 1000mg bid Lisinopril 10mg a day atorvastatin 40mg a day Labs today showed the following
bull Hgba1c 86 cmp eGFR 50 lipid WNL proteincr ratio 650mg These results are similar to her last visit
bull Upon further hx-you find that she had a recent eye exam and has mild nonproliferaive retinopathy She does not have neuropathy or other ss
bull What further workup do you need
bull Renal sonogram urine micro iPTH vit D (25 OH) phos uric acid
bull Dx stage
bull G3a A3
bull What further treatment do you need
bull Improve glycemic control Increase Lisinopril to 20mg with a goal of 40mg Avoid NSAIDs or other nephrotoxic agents make sure meds are renally dosed monitor 3xyear nephro referral
MANAGEMENT OF CKD IN DIABETESeGFR Recommended
All patients
Yearly measurement of creatinine urinary albumin excretion potassium
45-60 Referral to a nephrologist if possibility for nondiabetickidney disease existsConsider dose adjustment of medicationsMonitor eGFR every 6 monthsMonitor electrolytes bicarbonate hemoglobin calcium phosphorus parathyroid hormone at least yearly
Assure vitamin D sufficiencyConsider bone density testingReferral for dietary counselling
American Diabetes Association Standards of Medical Care in Diabetes Microvascular complications and foot care Diabetes Care 2017 40 (Suppl 1) S88-S98
CASE 3
bull 19 year old African American woman presents to your clinic with complaints of fatigue joint pains a new rash on her face oral ulcer
bull On exam BP 15080 P 88 Afebrile 96 O2 sats on RAbull GEN No respiratory distress at restbull HEENT painless oral ulcer flat rash over malar eminences sparing the nasolabial fold pallor +bull Lungs CTAbull CVS S1S2 regularbull Abdomen soft NTbull Ext left elbow joint and bilateral wrist joints are swollen and tender
bull What would you orderbull CBC CMP ua urine microscopy (microalbumin or urine proteincr ratio) ANA esr RF anti-ccp uric acid TSH
CASE 3
bull Working dx fatigue oral ulcer joint pain
bull Basic Labs Na 135 K 55 Bicarb 18 BUN 50 Cr 35 eGFR 22 Ca 90 ANA + titer 1640
bull UA 3+ blood 3+ protein RBC casts +
bull Given these results what is the most likely diagnosis
bull What would you do
SYSTEMIC LUPUS ERYTHEMATOSUS (SLE)
bull SLE multisystemic disease Etiology unknown
bull Production of autoantibodies and immune complexes formation
bull There is renal involvement in the great majority of patients with SLE at some time of the evolution 66-90
SLE ndash LUPUS NEPHRITIS
bull Race SLE is more commonsevere in African americans than Caucasiansbull
bull Gender female-to-male ratio of 91
bull Age Most patients develop lupus nephritis early in their disease course SLE is more common among women in the third decade of life and lupus nephritis occurs in patients aged 20-40 years
bull Kidney Biopsy For staging lupus nephritis (Class 1-5)
CASE 5bull A 80 year old man who has not seen a PCP in many years
presents to your clinic for weakness for the past few months On further questioning he tells you that his bones also have been hurting lately and he has developed leg swelling in the past month or so
bull On exam bull BP 16090 P 88 Afebrilebull GEN Thin built manbull HEENT pallor presentbull Lungs clearbull CVS S1S2 regular no rub or gallopbull Abdomen soft NTbull Ext 2 + edema
CASE 5
bull Differentials
bull CHF MI Cancer arthritis
bull Labs
bull CBC CMP urine microscopy urine proteincr ratio ESR TSH EKG BNP pa and lat CXR
bull LABS Urine dipstick negative for protein or blood
bull Basic chem bull Na 136 (135-145) K 51 (35-55) Chloride 108 (96-106) Bicarb 25
Given this presentation and the labs (low anion gap and elevated calcium anemia kidney failure) what will you think of What will you order next
Serum and urine protein electrophoresis
Intratubular refractile casts with surrounding syncytial giant cell reaction with chronic tubulointerstitial nephritis and fibrosis characteristic of myeloma cast nephropathy
Kidney Biopsy
CASE STUDYbull A 35 year old African American woman was seen in the clinic for
chronic cough and dyspnea on exertion She gave history of vague symptoms of fatigue and weight loss of 20 Ibs over the last six months
bull List some differentialsbull TB sarcoid lupus thyroid problems PEbull What would you orderbull PPD cbc cmp UA TSH ANA pa and lat cxr
bull Her labs were significant for mildly elevated calcium level and a creatinine of 20 mgdL eGFR 37
bull She had 750 mg of proteinuriaday
bull PPD neg ANA neg TSH and other labs WNL
bull Assuming this is present more than 3 monthshelliphellipwhat is her ckd stage
bull G3b A3
bull What do we still need
CT scan of chest
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileAnterior_mediastinal_mass_thymomajpgCreative Commons License associated httpcreativecommonsorglicensesby20deeden
CXR ndash HILAR LYMPHADENOPATHY
WHATS NEEDED NEXT
bull Biopsy of hilar lymphadenopathy or renal biopsy
bull DX sarcoidosis
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileSarcoidosis_signs_and_symptomsjpgThis work is in the public domain in the United States because it is a work of the United States Federal Government under the terms of Title 17 Chapter 1 Section 105 of the US Code
NEWLY DX CKD
bull 1) urinalysis microscopy ultrasound proteincr ratio
bull If obstruction-treat
bull No obstruction
bull Hx critical (consider myeloma if high risk)
bull glomerular bleeding or albumin in urine
bull Yes workup for glomerular causes (ANArf hep B C upep spep ANCA complement C3 C4)
bull No sterile pyruria-consider interstitial nephritis
bull High risk renovascular disease Evaluate renovascular disease
Additional Online Resources for CKD LearningbullNational Kidney Foundation wwwkidneyorgbullUnited States Renal Data Service wwwusrdsorgbullCDCrsquos CKD Surveillance Project
httpnccdcdcgovckdbullNational Kidney Disease Education Program
(NKDEP) httpnkdepnihgov
BIBLIOGRAPHY
bull Afzali B amp Goldsmith D J (2016 June 29) Statins and chronic kidney disease (G C Curhan amp A M Sheridan Eds) Retrieved 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsstatins-and-chronic-kidney-disease
bull American Diabetes Association Standards of Medical Care in Diabetes (2017) Microvascular complications and foot care Diabetes Care 2017 (40) S88-S98
bull American Diabetes Association Standards of Medical Care in Diabetes (2017) Microvascular complications and foot care Diabetes Care 40 (suppl 1) S88-S98
bull Berns J S (2017 Mar 22) Treatment of anemia in nondialysis chronic kidney disease (T A Golper amp A M Sheridan Eds) Retrieved from UpToDate httpswww-uptodate-comproxywichitaeducontentstreatment-of-anemia-in-nondialysis-chronic-kidney-disease
bull Chan M Dall A T Fletcher K E Lu N amp Trivedi H (2007) Outcomes in patients with chronic kidney disease referred late to nephrologists a meta-analysis American Journal of Medicine 120(12) 1063-1070
bull Coresh J Selvin E amp Stevens L A (2007) Prevalence of chronic kidny disease in the United States JAMA 298(17) doi101001jama298172038
bull de Brito-Ashurst I Varagunam M Raftery M amp Yagoob M (2009) Bicarbonate supplementation slows progression of CKD and improves nutritional status Journal of American Society of Nephrology (20) 2075-2084
BIBLIOGRAPHY
bull Duncan L Heathcoat J Djurdjev O amp Levin A (2001) Screening for renal disease using serum creatinine who are we missing Nephrology Dialysis and Transplant 16(5) 1042-1046
bull Dunkler D Gao P Lee S F Heinz G Clase C M Tobe S Oberbauer R (2015 August 7) Risk prediction for early CKD in type 2 diabetes Retrieved from Clinical Journal of the American Society of Nephrology httpcjasnasnjournalsorgcontent1081371fullsid=61422554-a5f1-41ac-b696-dcd3b12bd268
bull Fatehi P amp Chi-yuan H (September 15 2016) Diagnostic approach to the patient with newly identified chronic kidney disease (G C Curhan amp A M Sheridan Eds) Retrieved May 7 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsdiagnostic-approach-to-the-patient-with-newly-identified-chronic-kidney-disease
bull Fink J e (2009) Chronic Kidney Disease as an Under-Recognized Threat to Patient Safety American journal of kidney diseases the official journal of the National Kidney Foundation 53(4) 681-688
bull Gaffo A L amp Saag K G (2008 Nov) Management of hyperuricemia and gout in CKD doihttpdxdoiorg101053jajkd200807035
bull Hebert L A amp Parikh S V (2014 June 18) Differential diagnosis and evaluation of glomerular disease (R J Glassock amp A Q Lam Eds) Retrieved May 7 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsdifferential-diagnosis-and-evaluation-of-glomerular-disease
bull Inker L Perrone R D Sterns R H amp Forman J P (2017 March 7) Assessment of kidney function Retrieved from UpToDate httpswww-uptodate-comproxywichitaeducontentsassessment-of-kidney-functionsource=search_resultampsearch=creatinineampselectedTitle=1~150
BIBLIOGRAPHY
bull James P A Ortiz E amp Et Al (2014) Evidence based guideline for the management of high blood pressure in adults (JNC) JAMA 311(5) 507-520
bull Kidney Disease Improving Global Outcomes (KDIGO) CKD Work Group (2013 January) KDIGO 2012 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease Retrieved from Kidney International Supplement httpwwwkidney-internationalorg
bull Kunz R Friedrich C Wolbers M amp Mann J F (2008) Meta-analysis effect of monotherapy and combination therapy with inhibitors of the renin angiotensin system on proteinuria in renal disease Annals of Internal Medicine 148(1) 30-48
bull Levey A Stevens L A Schmid C H Castro A F Feldman H I Kusek J W Coresh J (2009) A new equation to estimate glomerular filtration rate Annals of Internal Medicine 150(9) 604-612
bull Levin A Bakris G L Molitch M Smulders M M Williams L A amp Andress D L (2007 Jan) Prevalence of abnormal serum vitamin D PTH calcium and phosphorus in patients with chronic kidney disease results of the study to evaluate early kidney disease Kidney International 71(1) 31-38 Retrieved from PubMED
bull Mahajan A Simoni J Sheather S Broglio K Rajab M amp Wesson D (2010) Daily oral sodium bicarbonate preserves glomerular filtration rate by slowing its decline in early hypertensive nephropathy Kidney International (78_ 303-309
bull Mann J Schmieder R E amp McQueen M (2008) Renal outcomes with telmisartan ramipril or both in people at high vascular risk (the ONTARGET study) a multicentre randomised doubleblind ocntrolled trial Lancet 372(9638) 547-533
BIBLIOGRAPHY
bull Matovinović M S (2009) Pathophysiology and classification of kidney disease Retrieved from The Journal of the International Federation of Clinical Chemistry and Laboratory Medicine httpwwwifccorgifccfilesdocs20010902pdf
bull Moe S Drueke T Lameire N amp Eknoyan G (2007 Jan) Chronic kidney disease-mineral-bone disorder a new paradigmdoi101053jackd200610005
bull Murtagh F E Marsh J E Donohoe P Ekbal N J Sheerin N S amp Harris F E (2007 July) Dialysis or not A comparative survival study of patients over 75 years with chronic kidney disease stage 5 Retrieved from Nephrology Dialysis and Transplant 22(7) httpswwwncbinlmnihgovpubmed17412702
bull National Kidney Foundation (2002) KDOQI clinical practice guidelines for chronic kidney disease evaluation classification andstratification American Journal of Kidney Disease S1-S266
bull National Kidney Foundation (2014 November 5) Fact Sheets Retrieved from httpwwwkidneyorgnewsnewsroomfactsheetsFastFacts
bull Pal S (2012 June 2) Trends in chronic kidney disease Retrieved from US Pharmacist (37)6 httpswwwuspharmacistcomarticletrends-in-chronic-kidney-disease
bull Qunibi W amp Henrich W L (2017 Jan 19) Overview of chronic kidney disease-mineral and bone disorder (J Berns amp A M Sheridan Eds) Retrieved from UpToDate httpswww-uptodate-comoverview-of-chronic-kidney-disease-mineral-and-bone-disorder-ckd-mbd
bull Rosenberg M (2016 Feb 24) Overview of the management of chronic kidney disease in adults (G C Curhan amp A M Sheridan Eds) Retrieved from UpToDate UpToDate httpswww-uptodate-comproxywichitaeducontentsoverview-of-the-management-of-chronic-kidney-disease-in-adults
BIBLIOGRAPHY
bull Szczech L Stewart R C Hsu-Lin S DeLosky R J Astor B C Fox C H Vassalotti J A (2014) Primary care detection of chronic kidney disease in adults with type 2 diabetes The ADD-CKD Study (Awareness Detection and Drug Therapy in type 2 diabetes and chronic kidney disease PLOS doihttpsdoiorg101371journalpone0110535
bull USRDS (2016) Annual data report 2016 Epidemiology of kidney disease in the United States Retrieved from United States Renal Data System httpswwwusrdsorgadraspx
bull Vasudev B amp Vasudev M (2012) A model curriculum for residents rotating in nephrology MedEDPORTAL doihttpdoiorg1015766mep_2374-82658288
bull Wei L MacDonald T M Jennings C Sheng X amp Flynn R W (2013) Estimated GFR reporting is associated with decreased nonsteroidal anti-inflammatory drug prescribing and increased renal function Kidney International (84)1 174-178
chronic kidney disease in primary care
CKD as a Public Health Issue
Slide Number 3
Costs of CKD in 2013 dollarsUSRDS report
Steps to CKD Patient Care
Renal anatomy and physiology
Definition of Chronic Kidney Disease
CKD Risk Factors
Gaps in CKD Diagnosis
Slide Number 10
Steps to CKD Patient Care
creatinine
Glomerular filtration rate
Slide Number 14
Slide Number 15
Use These Equations Cautiously if at all in hellip
lab albumin creatinine ratio
The New CKD Categories
Steps to CKD Patient Care
Slide Number 20
Kidney Involvement in Systemic Diseases
Slide Number 22
Slide Number 23
DysmorphicRenal Hematuria
Slide Number 25
If you have albuminuria or hematuria-order the following labs
bull In adults gt50 yrs statin when eGFR ge 60 mlmin173m2 statin or statinezetimibe combination when eGFR lt 60 mlmin173m2
bull In adults lt 50 yrs statin if history of known CAD MI DM strokebull Aspirin is indicated for secondary but not primary prevention
Kidney Disease Improving Global Outcomes (KDIGO) CKD Work Group Kidney Int Suppls 201331-150
STATINS-RENOPROTECTIVECONTROVERSY
bull HMG-CoA reductase inhibitors (statins) in high doses can cause proteinuria
bull Possibly associated with less inflammation endothelial dysfunction and scarring in the kidney because they also block inflammatory cytokines
bull Use statins for CV disease not to treat proteinuria
(Afzali and Goldsmith 2016)
MEDICINE CAUTION
bull Hold metformin when gfr lt35 mlmin
bull GFR lt50 mlmin should alert to check all doses of meds
bull No bisphosphanates lt35 mlmin
bull No NSAIDScox 2 inhibitors lt60 mlmin
bull Atenolol ndashrenal excretion
bull BACTRIM A lot of AKI
MEDICINE CAUTION
bull Lovenox-use subcut heparinbull Apixibanbull Dabigatranbull Rivaroxibanbull Lithiumbull GABAPENTIN (ckd 4 max 300mg qd ckd 5 max 300mg qod)
STEPS TO CKD PATIENT CARE
1 CKD definition and risks2 Assess GFR albuminuria3 Determine etiology4 Assess for evidence of progression5 Assess for associated complications6 Discuss dialysistransplantation
CKD-CVD-DIABETES LINK CKD IS A DISEASE MULTIPLIER
National kidney foundation 2014
KDIGO 2017
CKD-MINERAL BONE DISORDERS
bull As kidneys fail they
bull Stop activating calcitriol (the active form of Vit D)mdashcausing calcium imbalance
bull Do not remove phosphorus from bloodmdashleading to phosphorus retention
bull The extra phosphorus pulls calcium out of bones causing them to weaken
bull High phosphorus stimulates PTH release
bull These changes (plus others) cause the start of secondary hyperparathyroidism
bull Labs
bull eGFR
bull Calcium
bull Phos
bull Vit D
bull iPTH
(Qunibi amp Henrich 2017)
PREVALENCE OF ABNORMALITIES OF MINERAL METABOLISM PTH IN CKD
bull Progression of disease ndash declining eGFR increasing proteinuria
bull Degree of proteinuria nephrotic syndrome gt 05-10 gd on ACEi or ARB therapy
bull Etiology of CKD not certain
bull Need help with disease management
bull Indications for kidney biopsy
Rosenberg 2016
WHEN TO REFER
STEPS TO CKD PATIENT CARE
1 CKD definition and risks2 Assess GFR albuminuria3 Determine etiology4 Assess for evidence of progression5 Assess for associated complications6 Discuss dialysistransplantation
KIDNEY TRANSPLANTATION
bull Treatment of choice for ESRDbull Improves quality of lifebull Waiting list time varies-3-5 yearsbull 3 year survival rate after transplantation is 83-94bull Increased risk of cancer
STARTING DIALYSIS IN THE ELDERLYhellipOR NOT
bull Among patients gt 75 yrs with stage 5 CKD who chose to NOT start dialysisbull Overall more likely to die over next 1-2 years bull But if they had ischemic heart disease or other significant comorbidity NO
DIFFERENCE in survival
bull Active disease management and supportive care may be appropriate without starting dialysis in the ill elderly
bull Palliative care does not mean ldquono carerdquo
bull Must have end-of-life discussions
(Murtagh et al 2007)
CKD MANAGEMENTbull Diagnose cause and treat underlying conditionbull Stage per guidelinesbull Slow progression of kidney disease (ACE inhibitors)bull Monitor for complicationsmdashvolume overload hyperkalemia metabolic acidosis
hyperphosphatemia anorexia fatigue htn bone diseasebull Labs cmp cbc phos Vit D 25OH iPTH urine microscopy uric acid urine
proteincr ratio-frequency based off heat map Get sono at least oncebull Vaccinate influenza hep B pneumococcalbull Eval ASCVD risk-likely needs statinbull Possible dexa (donrsquot give bisphosphonates if GFRlt35 let specialist manage)bull Refer to nephrology when eGFR is lt30 (sometimes if higher risk-refer earlier)
CASE 1
bull 55 year old man with past medical history of headaches presents to your office for his first time visit to a PCP in over 30 years
bull He has no past history of being admitted to the hospital and he does not take any OTC medsNSAIDsherbal meds He has no history of ETOH abuse smoking or drug use
bull Vitals BP 180100 mmHg pulse 80 R 18
bull Exam No JVD S1S2 regular PMI shifted to the left no gallop no abdominal bruit pulses bilaterally equal and regular no leg edema
bull What would you order
bull EKG cbc cmp ua urine proteincr ratio lipid
LAB RESULTS
bull Labs reveal a creatinine of 22 mgdL eGFR 33 Urine shows no blood or casts Urineprotein ratio shows 1 gm protein24 hrs EKG shows LVH
bull Next step in workupbull Renal ultrasound 1st then SPEP UPEP with immunofixation serum free light chains
bull Additional labs neg Renal ultrasound shows that both kidneys are slightly reduced in size and are mildly echogenic with no mass or hydronephrosis
bull What is your diagnosis
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileMain_complications_of_persistent_high_blood_pressurepngCreative Commons License associated httpcreativecommonsorglicensesby-sa30
bull 3 months Howevermdashwe have evidence of structural abnormalities Could potentially stage at G3b A3 (red on the heat map)
bull Goal blood pressure
bull JNC 8 14090 NKF 13080
bull Additional lab needed for progression monitoring
bull Cbc renal panel phos Vit D iPTH uric acid urine micro (we already have the renal sono and urine proteincr ratio and lipid)
Selective renal angiography (left lower renal artery) after successful percutaneous balloon dilatation of the stenotic lesionFibromuscular dysplasia in an accessory renal artery causing renovascular hypertension
Secondary Hypertension
Images retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileRenal_FMD2jpg and httpcommonswikimediaorgwikiFileRenal_FMDjpgCreative Commons License associated httpcreativecommonsorglicensesby20deeden (both images)
CASE 2bull OS is a 64year old Hispanic female in for DM check She has had DM for 15+ years and is currently
taking metformin 1000mg bid Lisinopril 10mg a day atorvastatin 40mg a day Labs today showed the following
bull Hgba1c 86 cmp eGFR 50 lipid WNL proteincr ratio 650mg These results are similar to her last visit
bull Upon further hx-you find that she had a recent eye exam and has mild nonproliferaive retinopathy She does not have neuropathy or other ss
bull What further workup do you need
bull Renal sonogram urine micro iPTH vit D (25 OH) phos uric acid
bull Dx stage
bull G3a A3
bull What further treatment do you need
bull Improve glycemic control Increase Lisinopril to 20mg with a goal of 40mg Avoid NSAIDs or other nephrotoxic agents make sure meds are renally dosed monitor 3xyear nephro referral
MANAGEMENT OF CKD IN DIABETESeGFR Recommended
All patients
Yearly measurement of creatinine urinary albumin excretion potassium
45-60 Referral to a nephrologist if possibility for nondiabetickidney disease existsConsider dose adjustment of medicationsMonitor eGFR every 6 monthsMonitor electrolytes bicarbonate hemoglobin calcium phosphorus parathyroid hormone at least yearly
Assure vitamin D sufficiencyConsider bone density testingReferral for dietary counselling
American Diabetes Association Standards of Medical Care in Diabetes Microvascular complications and foot care Diabetes Care 2017 40 (Suppl 1) S88-S98
CASE 3
bull 19 year old African American woman presents to your clinic with complaints of fatigue joint pains a new rash on her face oral ulcer
bull On exam BP 15080 P 88 Afebrile 96 O2 sats on RAbull GEN No respiratory distress at restbull HEENT painless oral ulcer flat rash over malar eminences sparing the nasolabial fold pallor +bull Lungs CTAbull CVS S1S2 regularbull Abdomen soft NTbull Ext left elbow joint and bilateral wrist joints are swollen and tender
bull What would you orderbull CBC CMP ua urine microscopy (microalbumin or urine proteincr ratio) ANA esr RF anti-ccp uric acid TSH
CASE 3
bull Working dx fatigue oral ulcer joint pain
bull Basic Labs Na 135 K 55 Bicarb 18 BUN 50 Cr 35 eGFR 22 Ca 90 ANA + titer 1640
bull UA 3+ blood 3+ protein RBC casts +
bull Given these results what is the most likely diagnosis
bull What would you do
SYSTEMIC LUPUS ERYTHEMATOSUS (SLE)
bull SLE multisystemic disease Etiology unknown
bull Production of autoantibodies and immune complexes formation
bull There is renal involvement in the great majority of patients with SLE at some time of the evolution 66-90
SLE ndash LUPUS NEPHRITIS
bull Race SLE is more commonsevere in African americans than Caucasiansbull
bull Gender female-to-male ratio of 91
bull Age Most patients develop lupus nephritis early in their disease course SLE is more common among women in the third decade of life and lupus nephritis occurs in patients aged 20-40 years
bull Kidney Biopsy For staging lupus nephritis (Class 1-5)
CASE 5bull A 80 year old man who has not seen a PCP in many years
presents to your clinic for weakness for the past few months On further questioning he tells you that his bones also have been hurting lately and he has developed leg swelling in the past month or so
bull On exam bull BP 16090 P 88 Afebrilebull GEN Thin built manbull HEENT pallor presentbull Lungs clearbull CVS S1S2 regular no rub or gallopbull Abdomen soft NTbull Ext 2 + edema
CASE 5
bull Differentials
bull CHF MI Cancer arthritis
bull Labs
bull CBC CMP urine microscopy urine proteincr ratio ESR TSH EKG BNP pa and lat CXR
bull LABS Urine dipstick negative for protein or blood
bull Basic chem bull Na 136 (135-145) K 51 (35-55) Chloride 108 (96-106) Bicarb 25
Given this presentation and the labs (low anion gap and elevated calcium anemia kidney failure) what will you think of What will you order next
Serum and urine protein electrophoresis
Intratubular refractile casts with surrounding syncytial giant cell reaction with chronic tubulointerstitial nephritis and fibrosis characteristic of myeloma cast nephropathy
Kidney Biopsy
CASE STUDYbull A 35 year old African American woman was seen in the clinic for
chronic cough and dyspnea on exertion She gave history of vague symptoms of fatigue and weight loss of 20 Ibs over the last six months
bull List some differentialsbull TB sarcoid lupus thyroid problems PEbull What would you orderbull PPD cbc cmp UA TSH ANA pa and lat cxr
bull Her labs were significant for mildly elevated calcium level and a creatinine of 20 mgdL eGFR 37
bull She had 750 mg of proteinuriaday
bull PPD neg ANA neg TSH and other labs WNL
bull Assuming this is present more than 3 monthshelliphellipwhat is her ckd stage
bull G3b A3
bull What do we still need
CT scan of chest
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileAnterior_mediastinal_mass_thymomajpgCreative Commons License associated httpcreativecommonsorglicensesby20deeden
CXR ndash HILAR LYMPHADENOPATHY
WHATS NEEDED NEXT
bull Biopsy of hilar lymphadenopathy or renal biopsy
bull DX sarcoidosis
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileSarcoidosis_signs_and_symptomsjpgThis work is in the public domain in the United States because it is a work of the United States Federal Government under the terms of Title 17 Chapter 1 Section 105 of the US Code
NEWLY DX CKD
bull 1) urinalysis microscopy ultrasound proteincr ratio
bull If obstruction-treat
bull No obstruction
bull Hx critical (consider myeloma if high risk)
bull glomerular bleeding or albumin in urine
bull Yes workup for glomerular causes (ANArf hep B C upep spep ANCA complement C3 C4)
bull No sterile pyruria-consider interstitial nephritis
bull High risk renovascular disease Evaluate renovascular disease
Additional Online Resources for CKD LearningbullNational Kidney Foundation wwwkidneyorgbullUnited States Renal Data Service wwwusrdsorgbullCDCrsquos CKD Surveillance Project
httpnccdcdcgovckdbullNational Kidney Disease Education Program
(NKDEP) httpnkdepnihgov
BIBLIOGRAPHY
bull Afzali B amp Goldsmith D J (2016 June 29) Statins and chronic kidney disease (G C Curhan amp A M Sheridan Eds) Retrieved 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsstatins-and-chronic-kidney-disease
bull American Diabetes Association Standards of Medical Care in Diabetes (2017) Microvascular complications and foot care Diabetes Care 2017 (40) S88-S98
bull American Diabetes Association Standards of Medical Care in Diabetes (2017) Microvascular complications and foot care Diabetes Care 40 (suppl 1) S88-S98
bull Berns J S (2017 Mar 22) Treatment of anemia in nondialysis chronic kidney disease (T A Golper amp A M Sheridan Eds) Retrieved from UpToDate httpswww-uptodate-comproxywichitaeducontentstreatment-of-anemia-in-nondialysis-chronic-kidney-disease
bull Chan M Dall A T Fletcher K E Lu N amp Trivedi H (2007) Outcomes in patients with chronic kidney disease referred late to nephrologists a meta-analysis American Journal of Medicine 120(12) 1063-1070
bull Coresh J Selvin E amp Stevens L A (2007) Prevalence of chronic kidny disease in the United States JAMA 298(17) doi101001jama298172038
bull de Brito-Ashurst I Varagunam M Raftery M amp Yagoob M (2009) Bicarbonate supplementation slows progression of CKD and improves nutritional status Journal of American Society of Nephrology (20) 2075-2084
BIBLIOGRAPHY
bull Duncan L Heathcoat J Djurdjev O amp Levin A (2001) Screening for renal disease using serum creatinine who are we missing Nephrology Dialysis and Transplant 16(5) 1042-1046
bull Dunkler D Gao P Lee S F Heinz G Clase C M Tobe S Oberbauer R (2015 August 7) Risk prediction for early CKD in type 2 diabetes Retrieved from Clinical Journal of the American Society of Nephrology httpcjasnasnjournalsorgcontent1081371fullsid=61422554-a5f1-41ac-b696-dcd3b12bd268
bull Fatehi P amp Chi-yuan H (September 15 2016) Diagnostic approach to the patient with newly identified chronic kidney disease (G C Curhan amp A M Sheridan Eds) Retrieved May 7 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsdiagnostic-approach-to-the-patient-with-newly-identified-chronic-kidney-disease
bull Fink J e (2009) Chronic Kidney Disease as an Under-Recognized Threat to Patient Safety American journal of kidney diseases the official journal of the National Kidney Foundation 53(4) 681-688
bull Gaffo A L amp Saag K G (2008 Nov) Management of hyperuricemia and gout in CKD doihttpdxdoiorg101053jajkd200807035
bull Hebert L A amp Parikh S V (2014 June 18) Differential diagnosis and evaluation of glomerular disease (R J Glassock amp A Q Lam Eds) Retrieved May 7 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsdifferential-diagnosis-and-evaluation-of-glomerular-disease
bull Inker L Perrone R D Sterns R H amp Forman J P (2017 March 7) Assessment of kidney function Retrieved from UpToDate httpswww-uptodate-comproxywichitaeducontentsassessment-of-kidney-functionsource=search_resultampsearch=creatinineampselectedTitle=1~150
BIBLIOGRAPHY
bull James P A Ortiz E amp Et Al (2014) Evidence based guideline for the management of high blood pressure in adults (JNC) JAMA 311(5) 507-520
bull Kidney Disease Improving Global Outcomes (KDIGO) CKD Work Group (2013 January) KDIGO 2012 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease Retrieved from Kidney International Supplement httpwwwkidney-internationalorg
bull Kunz R Friedrich C Wolbers M amp Mann J F (2008) Meta-analysis effect of monotherapy and combination therapy with inhibitors of the renin angiotensin system on proteinuria in renal disease Annals of Internal Medicine 148(1) 30-48
bull Levey A Stevens L A Schmid C H Castro A F Feldman H I Kusek J W Coresh J (2009) A new equation to estimate glomerular filtration rate Annals of Internal Medicine 150(9) 604-612
bull Levin A Bakris G L Molitch M Smulders M M Williams L A amp Andress D L (2007 Jan) Prevalence of abnormal serum vitamin D PTH calcium and phosphorus in patients with chronic kidney disease results of the study to evaluate early kidney disease Kidney International 71(1) 31-38 Retrieved from PubMED
bull Mahajan A Simoni J Sheather S Broglio K Rajab M amp Wesson D (2010) Daily oral sodium bicarbonate preserves glomerular filtration rate by slowing its decline in early hypertensive nephropathy Kidney International (78_ 303-309
bull Mann J Schmieder R E amp McQueen M (2008) Renal outcomes with telmisartan ramipril or both in people at high vascular risk (the ONTARGET study) a multicentre randomised doubleblind ocntrolled trial Lancet 372(9638) 547-533
BIBLIOGRAPHY
bull Matovinović M S (2009) Pathophysiology and classification of kidney disease Retrieved from The Journal of the International Federation of Clinical Chemistry and Laboratory Medicine httpwwwifccorgifccfilesdocs20010902pdf
bull Moe S Drueke T Lameire N amp Eknoyan G (2007 Jan) Chronic kidney disease-mineral-bone disorder a new paradigmdoi101053jackd200610005
bull Murtagh F E Marsh J E Donohoe P Ekbal N J Sheerin N S amp Harris F E (2007 July) Dialysis or not A comparative survival study of patients over 75 years with chronic kidney disease stage 5 Retrieved from Nephrology Dialysis and Transplant 22(7) httpswwwncbinlmnihgovpubmed17412702
bull National Kidney Foundation (2002) KDOQI clinical practice guidelines for chronic kidney disease evaluation classification andstratification American Journal of Kidney Disease S1-S266
bull National Kidney Foundation (2014 November 5) Fact Sheets Retrieved from httpwwwkidneyorgnewsnewsroomfactsheetsFastFacts
bull Pal S (2012 June 2) Trends in chronic kidney disease Retrieved from US Pharmacist (37)6 httpswwwuspharmacistcomarticletrends-in-chronic-kidney-disease
bull Qunibi W amp Henrich W L (2017 Jan 19) Overview of chronic kidney disease-mineral and bone disorder (J Berns amp A M Sheridan Eds) Retrieved from UpToDate httpswww-uptodate-comoverview-of-chronic-kidney-disease-mineral-and-bone-disorder-ckd-mbd
bull Rosenberg M (2016 Feb 24) Overview of the management of chronic kidney disease in adults (G C Curhan amp A M Sheridan Eds) Retrieved from UpToDate UpToDate httpswww-uptodate-comproxywichitaeducontentsoverview-of-the-management-of-chronic-kidney-disease-in-adults
BIBLIOGRAPHY
bull Szczech L Stewart R C Hsu-Lin S DeLosky R J Astor B C Fox C H Vassalotti J A (2014) Primary care detection of chronic kidney disease in adults with type 2 diabetes The ADD-CKD Study (Awareness Detection and Drug Therapy in type 2 diabetes and chronic kidney disease PLOS doihttpsdoiorg101371journalpone0110535
bull USRDS (2016) Annual data report 2016 Epidemiology of kidney disease in the United States Retrieved from United States Renal Data System httpswwwusrdsorgadraspx
bull Vasudev B amp Vasudev M (2012) A model curriculum for residents rotating in nephrology MedEDPORTAL doihttpdoiorg1015766mep_2374-82658288
bull Wei L MacDonald T M Jennings C Sheng X amp Flynn R W (2013) Estimated GFR reporting is associated with decreased nonsteroidal anti-inflammatory drug prescribing and increased renal function Kidney International (84)1 174-178
chronic kidney disease in primary care
CKD as a Public Health Issue
Slide Number 3
Costs of CKD in 2013 dollarsUSRDS report
Steps to CKD Patient Care
Renal anatomy and physiology
Definition of Chronic Kidney Disease
CKD Risk Factors
Gaps in CKD Diagnosis
Slide Number 10
Steps to CKD Patient Care
creatinine
Glomerular filtration rate
Slide Number 14
Slide Number 15
Use These Equations Cautiously if at all in hellip
lab albumin creatinine ratio
The New CKD Categories
Steps to CKD Patient Care
Slide Number 20
Kidney Involvement in Systemic Diseases
Slide Number 22
Slide Number 23
DysmorphicRenal Hematuria
Slide Number 25
If you have albuminuria or hematuria-order the following labs
bull In adults gt50 yrs statin when eGFR ge 60 mlmin173m2 statin or statinezetimibe combination when eGFR lt 60 mlmin173m2
bull In adults lt 50 yrs statin if history of known CAD MI DM strokebull Aspirin is indicated for secondary but not primary prevention
Kidney Disease Improving Global Outcomes (KDIGO) CKD Work Group Kidney Int Suppls 201331-150
STATINS-RENOPROTECTIVECONTROVERSY
bull HMG-CoA reductase inhibitors (statins) in high doses can cause proteinuria
bull Possibly associated with less inflammation endothelial dysfunction and scarring in the kidney because they also block inflammatory cytokines
bull Use statins for CV disease not to treat proteinuria
(Afzali and Goldsmith 2016)
MEDICINE CAUTION
bull Hold metformin when gfr lt35 mlmin
bull GFR lt50 mlmin should alert to check all doses of meds
bull No bisphosphanates lt35 mlmin
bull No NSAIDScox 2 inhibitors lt60 mlmin
bull Atenolol ndashrenal excretion
bull BACTRIM A lot of AKI
MEDICINE CAUTION
bull Lovenox-use subcut heparinbull Apixibanbull Dabigatranbull Rivaroxibanbull Lithiumbull GABAPENTIN (ckd 4 max 300mg qd ckd 5 max 300mg qod)
STEPS TO CKD PATIENT CARE
1 CKD definition and risks2 Assess GFR albuminuria3 Determine etiology4 Assess for evidence of progression5 Assess for associated complications6 Discuss dialysistransplantation
CKD-CVD-DIABETES LINK CKD IS A DISEASE MULTIPLIER
National kidney foundation 2014
KDIGO 2017
CKD-MINERAL BONE DISORDERS
bull As kidneys fail they
bull Stop activating calcitriol (the active form of Vit D)mdashcausing calcium imbalance
bull Do not remove phosphorus from bloodmdashleading to phosphorus retention
bull The extra phosphorus pulls calcium out of bones causing them to weaken
bull High phosphorus stimulates PTH release
bull These changes (plus others) cause the start of secondary hyperparathyroidism
bull Labs
bull eGFR
bull Calcium
bull Phos
bull Vit D
bull iPTH
(Qunibi amp Henrich 2017)
PREVALENCE OF ABNORMALITIES OF MINERAL METABOLISM PTH IN CKD
bull Progression of disease ndash declining eGFR increasing proteinuria
bull Degree of proteinuria nephrotic syndrome gt 05-10 gd on ACEi or ARB therapy
bull Etiology of CKD not certain
bull Need help with disease management
bull Indications for kidney biopsy
Rosenberg 2016
WHEN TO REFER
STEPS TO CKD PATIENT CARE
1 CKD definition and risks2 Assess GFR albuminuria3 Determine etiology4 Assess for evidence of progression5 Assess for associated complications6 Discuss dialysistransplantation
KIDNEY TRANSPLANTATION
bull Treatment of choice for ESRDbull Improves quality of lifebull Waiting list time varies-3-5 yearsbull 3 year survival rate after transplantation is 83-94bull Increased risk of cancer
STARTING DIALYSIS IN THE ELDERLYhellipOR NOT
bull Among patients gt 75 yrs with stage 5 CKD who chose to NOT start dialysisbull Overall more likely to die over next 1-2 years bull But if they had ischemic heart disease or other significant comorbidity NO
DIFFERENCE in survival
bull Active disease management and supportive care may be appropriate without starting dialysis in the ill elderly
bull Palliative care does not mean ldquono carerdquo
bull Must have end-of-life discussions
(Murtagh et al 2007)
CKD MANAGEMENTbull Diagnose cause and treat underlying conditionbull Stage per guidelinesbull Slow progression of kidney disease (ACE inhibitors)bull Monitor for complicationsmdashvolume overload hyperkalemia metabolic acidosis
hyperphosphatemia anorexia fatigue htn bone diseasebull Labs cmp cbc phos Vit D 25OH iPTH urine microscopy uric acid urine
proteincr ratio-frequency based off heat map Get sono at least oncebull Vaccinate influenza hep B pneumococcalbull Eval ASCVD risk-likely needs statinbull Possible dexa (donrsquot give bisphosphonates if GFRlt35 let specialist manage)bull Refer to nephrology when eGFR is lt30 (sometimes if higher risk-refer earlier)
CASE 1
bull 55 year old man with past medical history of headaches presents to your office for his first time visit to a PCP in over 30 years
bull He has no past history of being admitted to the hospital and he does not take any OTC medsNSAIDsherbal meds He has no history of ETOH abuse smoking or drug use
bull Vitals BP 180100 mmHg pulse 80 R 18
bull Exam No JVD S1S2 regular PMI shifted to the left no gallop no abdominal bruit pulses bilaterally equal and regular no leg edema
bull What would you order
bull EKG cbc cmp ua urine proteincr ratio lipid
LAB RESULTS
bull Labs reveal a creatinine of 22 mgdL eGFR 33 Urine shows no blood or casts Urineprotein ratio shows 1 gm protein24 hrs EKG shows LVH
bull Next step in workupbull Renal ultrasound 1st then SPEP UPEP with immunofixation serum free light chains
bull Additional labs neg Renal ultrasound shows that both kidneys are slightly reduced in size and are mildly echogenic with no mass or hydronephrosis
bull What is your diagnosis
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileMain_complications_of_persistent_high_blood_pressurepngCreative Commons License associated httpcreativecommonsorglicensesby-sa30
bull 3 months Howevermdashwe have evidence of structural abnormalities Could potentially stage at G3b A3 (red on the heat map)
bull Goal blood pressure
bull JNC 8 14090 NKF 13080
bull Additional lab needed for progression monitoring
bull Cbc renal panel phos Vit D iPTH uric acid urine micro (we already have the renal sono and urine proteincr ratio and lipid)
Selective renal angiography (left lower renal artery) after successful percutaneous balloon dilatation of the stenotic lesionFibromuscular dysplasia in an accessory renal artery causing renovascular hypertension
Secondary Hypertension
Images retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileRenal_FMD2jpg and httpcommonswikimediaorgwikiFileRenal_FMDjpgCreative Commons License associated httpcreativecommonsorglicensesby20deeden (both images)
CASE 2bull OS is a 64year old Hispanic female in for DM check She has had DM for 15+ years and is currently
taking metformin 1000mg bid Lisinopril 10mg a day atorvastatin 40mg a day Labs today showed the following
bull Hgba1c 86 cmp eGFR 50 lipid WNL proteincr ratio 650mg These results are similar to her last visit
bull Upon further hx-you find that she had a recent eye exam and has mild nonproliferaive retinopathy She does not have neuropathy or other ss
bull What further workup do you need
bull Renal sonogram urine micro iPTH vit D (25 OH) phos uric acid
bull Dx stage
bull G3a A3
bull What further treatment do you need
bull Improve glycemic control Increase Lisinopril to 20mg with a goal of 40mg Avoid NSAIDs or other nephrotoxic agents make sure meds are renally dosed monitor 3xyear nephro referral
MANAGEMENT OF CKD IN DIABETESeGFR Recommended
All patients
Yearly measurement of creatinine urinary albumin excretion potassium
45-60 Referral to a nephrologist if possibility for nondiabetickidney disease existsConsider dose adjustment of medicationsMonitor eGFR every 6 monthsMonitor electrolytes bicarbonate hemoglobin calcium phosphorus parathyroid hormone at least yearly
Assure vitamin D sufficiencyConsider bone density testingReferral for dietary counselling
American Diabetes Association Standards of Medical Care in Diabetes Microvascular complications and foot care Diabetes Care 2017 40 (Suppl 1) S88-S98
CASE 3
bull 19 year old African American woman presents to your clinic with complaints of fatigue joint pains a new rash on her face oral ulcer
bull On exam BP 15080 P 88 Afebrile 96 O2 sats on RAbull GEN No respiratory distress at restbull HEENT painless oral ulcer flat rash over malar eminences sparing the nasolabial fold pallor +bull Lungs CTAbull CVS S1S2 regularbull Abdomen soft NTbull Ext left elbow joint and bilateral wrist joints are swollen and tender
bull What would you orderbull CBC CMP ua urine microscopy (microalbumin or urine proteincr ratio) ANA esr RF anti-ccp uric acid TSH
CASE 3
bull Working dx fatigue oral ulcer joint pain
bull Basic Labs Na 135 K 55 Bicarb 18 BUN 50 Cr 35 eGFR 22 Ca 90 ANA + titer 1640
bull UA 3+ blood 3+ protein RBC casts +
bull Given these results what is the most likely diagnosis
bull What would you do
SYSTEMIC LUPUS ERYTHEMATOSUS (SLE)
bull SLE multisystemic disease Etiology unknown
bull Production of autoantibodies and immune complexes formation
bull There is renal involvement in the great majority of patients with SLE at some time of the evolution 66-90
SLE ndash LUPUS NEPHRITIS
bull Race SLE is more commonsevere in African americans than Caucasiansbull
bull Gender female-to-male ratio of 91
bull Age Most patients develop lupus nephritis early in their disease course SLE is more common among women in the third decade of life and lupus nephritis occurs in patients aged 20-40 years
bull Kidney Biopsy For staging lupus nephritis (Class 1-5)
CASE 5bull A 80 year old man who has not seen a PCP in many years
presents to your clinic for weakness for the past few months On further questioning he tells you that his bones also have been hurting lately and he has developed leg swelling in the past month or so
bull On exam bull BP 16090 P 88 Afebrilebull GEN Thin built manbull HEENT pallor presentbull Lungs clearbull CVS S1S2 regular no rub or gallopbull Abdomen soft NTbull Ext 2 + edema
CASE 5
bull Differentials
bull CHF MI Cancer arthritis
bull Labs
bull CBC CMP urine microscopy urine proteincr ratio ESR TSH EKG BNP pa and lat CXR
bull LABS Urine dipstick negative for protein or blood
bull Basic chem bull Na 136 (135-145) K 51 (35-55) Chloride 108 (96-106) Bicarb 25
Given this presentation and the labs (low anion gap and elevated calcium anemia kidney failure) what will you think of What will you order next
Serum and urine protein electrophoresis
Intratubular refractile casts with surrounding syncytial giant cell reaction with chronic tubulointerstitial nephritis and fibrosis characteristic of myeloma cast nephropathy
Kidney Biopsy
CASE STUDYbull A 35 year old African American woman was seen in the clinic for
chronic cough and dyspnea on exertion She gave history of vague symptoms of fatigue and weight loss of 20 Ibs over the last six months
bull List some differentialsbull TB sarcoid lupus thyroid problems PEbull What would you orderbull PPD cbc cmp UA TSH ANA pa and lat cxr
bull Her labs were significant for mildly elevated calcium level and a creatinine of 20 mgdL eGFR 37
bull She had 750 mg of proteinuriaday
bull PPD neg ANA neg TSH and other labs WNL
bull Assuming this is present more than 3 monthshelliphellipwhat is her ckd stage
bull G3b A3
bull What do we still need
CT scan of chest
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileAnterior_mediastinal_mass_thymomajpgCreative Commons License associated httpcreativecommonsorglicensesby20deeden
CXR ndash HILAR LYMPHADENOPATHY
WHATS NEEDED NEXT
bull Biopsy of hilar lymphadenopathy or renal biopsy
bull DX sarcoidosis
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileSarcoidosis_signs_and_symptomsjpgThis work is in the public domain in the United States because it is a work of the United States Federal Government under the terms of Title 17 Chapter 1 Section 105 of the US Code
NEWLY DX CKD
bull 1) urinalysis microscopy ultrasound proteincr ratio
bull If obstruction-treat
bull No obstruction
bull Hx critical (consider myeloma if high risk)
bull glomerular bleeding or albumin in urine
bull Yes workup for glomerular causes (ANArf hep B C upep spep ANCA complement C3 C4)
bull No sterile pyruria-consider interstitial nephritis
bull High risk renovascular disease Evaluate renovascular disease
Additional Online Resources for CKD LearningbullNational Kidney Foundation wwwkidneyorgbullUnited States Renal Data Service wwwusrdsorgbullCDCrsquos CKD Surveillance Project
httpnccdcdcgovckdbullNational Kidney Disease Education Program
(NKDEP) httpnkdepnihgov
BIBLIOGRAPHY
bull Afzali B amp Goldsmith D J (2016 June 29) Statins and chronic kidney disease (G C Curhan amp A M Sheridan Eds) Retrieved 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsstatins-and-chronic-kidney-disease
bull American Diabetes Association Standards of Medical Care in Diabetes (2017) Microvascular complications and foot care Diabetes Care 2017 (40) S88-S98
bull American Diabetes Association Standards of Medical Care in Diabetes (2017) Microvascular complications and foot care Diabetes Care 40 (suppl 1) S88-S98
bull Berns J S (2017 Mar 22) Treatment of anemia in nondialysis chronic kidney disease (T A Golper amp A M Sheridan Eds) Retrieved from UpToDate httpswww-uptodate-comproxywichitaeducontentstreatment-of-anemia-in-nondialysis-chronic-kidney-disease
bull Chan M Dall A T Fletcher K E Lu N amp Trivedi H (2007) Outcomes in patients with chronic kidney disease referred late to nephrologists a meta-analysis American Journal of Medicine 120(12) 1063-1070
bull Coresh J Selvin E amp Stevens L A (2007) Prevalence of chronic kidny disease in the United States JAMA 298(17) doi101001jama298172038
bull de Brito-Ashurst I Varagunam M Raftery M amp Yagoob M (2009) Bicarbonate supplementation slows progression of CKD and improves nutritional status Journal of American Society of Nephrology (20) 2075-2084
BIBLIOGRAPHY
bull Duncan L Heathcoat J Djurdjev O amp Levin A (2001) Screening for renal disease using serum creatinine who are we missing Nephrology Dialysis and Transplant 16(5) 1042-1046
bull Dunkler D Gao P Lee S F Heinz G Clase C M Tobe S Oberbauer R (2015 August 7) Risk prediction for early CKD in type 2 diabetes Retrieved from Clinical Journal of the American Society of Nephrology httpcjasnasnjournalsorgcontent1081371fullsid=61422554-a5f1-41ac-b696-dcd3b12bd268
bull Fatehi P amp Chi-yuan H (September 15 2016) Diagnostic approach to the patient with newly identified chronic kidney disease (G C Curhan amp A M Sheridan Eds) Retrieved May 7 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsdiagnostic-approach-to-the-patient-with-newly-identified-chronic-kidney-disease
bull Fink J e (2009) Chronic Kidney Disease as an Under-Recognized Threat to Patient Safety American journal of kidney diseases the official journal of the National Kidney Foundation 53(4) 681-688
bull Gaffo A L amp Saag K G (2008 Nov) Management of hyperuricemia and gout in CKD doihttpdxdoiorg101053jajkd200807035
bull Hebert L A amp Parikh S V (2014 June 18) Differential diagnosis and evaluation of glomerular disease (R J Glassock amp A Q Lam Eds) Retrieved May 7 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsdifferential-diagnosis-and-evaluation-of-glomerular-disease
bull Inker L Perrone R D Sterns R H amp Forman J P (2017 March 7) Assessment of kidney function Retrieved from UpToDate httpswww-uptodate-comproxywichitaeducontentsassessment-of-kidney-functionsource=search_resultampsearch=creatinineampselectedTitle=1~150
BIBLIOGRAPHY
bull James P A Ortiz E amp Et Al (2014) Evidence based guideline for the management of high blood pressure in adults (JNC) JAMA 311(5) 507-520
bull Kidney Disease Improving Global Outcomes (KDIGO) CKD Work Group (2013 January) KDIGO 2012 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease Retrieved from Kidney International Supplement httpwwwkidney-internationalorg
bull Kunz R Friedrich C Wolbers M amp Mann J F (2008) Meta-analysis effect of monotherapy and combination therapy with inhibitors of the renin angiotensin system on proteinuria in renal disease Annals of Internal Medicine 148(1) 30-48
bull Levey A Stevens L A Schmid C H Castro A F Feldman H I Kusek J W Coresh J (2009) A new equation to estimate glomerular filtration rate Annals of Internal Medicine 150(9) 604-612
bull Levin A Bakris G L Molitch M Smulders M M Williams L A amp Andress D L (2007 Jan) Prevalence of abnormal serum vitamin D PTH calcium and phosphorus in patients with chronic kidney disease results of the study to evaluate early kidney disease Kidney International 71(1) 31-38 Retrieved from PubMED
bull Mahajan A Simoni J Sheather S Broglio K Rajab M amp Wesson D (2010) Daily oral sodium bicarbonate preserves glomerular filtration rate by slowing its decline in early hypertensive nephropathy Kidney International (78_ 303-309
bull Mann J Schmieder R E amp McQueen M (2008) Renal outcomes with telmisartan ramipril or both in people at high vascular risk (the ONTARGET study) a multicentre randomised doubleblind ocntrolled trial Lancet 372(9638) 547-533
BIBLIOGRAPHY
bull Matovinović M S (2009) Pathophysiology and classification of kidney disease Retrieved from The Journal of the International Federation of Clinical Chemistry and Laboratory Medicine httpwwwifccorgifccfilesdocs20010902pdf
bull Moe S Drueke T Lameire N amp Eknoyan G (2007 Jan) Chronic kidney disease-mineral-bone disorder a new paradigmdoi101053jackd200610005
bull Murtagh F E Marsh J E Donohoe P Ekbal N J Sheerin N S amp Harris F E (2007 July) Dialysis or not A comparative survival study of patients over 75 years with chronic kidney disease stage 5 Retrieved from Nephrology Dialysis and Transplant 22(7) httpswwwncbinlmnihgovpubmed17412702
bull National Kidney Foundation (2002) KDOQI clinical practice guidelines for chronic kidney disease evaluation classification andstratification American Journal of Kidney Disease S1-S266
bull National Kidney Foundation (2014 November 5) Fact Sheets Retrieved from httpwwwkidneyorgnewsnewsroomfactsheetsFastFacts
bull Pal S (2012 June 2) Trends in chronic kidney disease Retrieved from US Pharmacist (37)6 httpswwwuspharmacistcomarticletrends-in-chronic-kidney-disease
bull Qunibi W amp Henrich W L (2017 Jan 19) Overview of chronic kidney disease-mineral and bone disorder (J Berns amp A M Sheridan Eds) Retrieved from UpToDate httpswww-uptodate-comoverview-of-chronic-kidney-disease-mineral-and-bone-disorder-ckd-mbd
bull Rosenberg M (2016 Feb 24) Overview of the management of chronic kidney disease in adults (G C Curhan amp A M Sheridan Eds) Retrieved from UpToDate UpToDate httpswww-uptodate-comproxywichitaeducontentsoverview-of-the-management-of-chronic-kidney-disease-in-adults
BIBLIOGRAPHY
bull Szczech L Stewart R C Hsu-Lin S DeLosky R J Astor B C Fox C H Vassalotti J A (2014) Primary care detection of chronic kidney disease in adults with type 2 diabetes The ADD-CKD Study (Awareness Detection and Drug Therapy in type 2 diabetes and chronic kidney disease PLOS doihttpsdoiorg101371journalpone0110535
bull USRDS (2016) Annual data report 2016 Epidemiology of kidney disease in the United States Retrieved from United States Renal Data System httpswwwusrdsorgadraspx
bull Vasudev B amp Vasudev M (2012) A model curriculum for residents rotating in nephrology MedEDPORTAL doihttpdoiorg1015766mep_2374-82658288
bull Wei L MacDonald T M Jennings C Sheng X amp Flynn R W (2013) Estimated GFR reporting is associated with decreased nonsteroidal anti-inflammatory drug prescribing and increased renal function Kidney International (84)1 174-178
chronic kidney disease in primary care
CKD as a Public Health Issue
Slide Number 3
Costs of CKD in 2013 dollarsUSRDS report
Steps to CKD Patient Care
Renal anatomy and physiology
Definition of Chronic Kidney Disease
CKD Risk Factors
Gaps in CKD Diagnosis
Slide Number 10
Steps to CKD Patient Care
creatinine
Glomerular filtration rate
Slide Number 14
Slide Number 15
Use These Equations Cautiously if at all in hellip
lab albumin creatinine ratio
The New CKD Categories
Steps to CKD Patient Care
Slide Number 20
Kidney Involvement in Systemic Diseases
Slide Number 22
Slide Number 23
DysmorphicRenal Hematuria
Slide Number 25
If you have albuminuria or hematuria-order the following labs
Prevalence of Abnormalities of Mineral Metabolism PTH in CKD
Managing CKD-MBD complications
CKD-MBD Testing
Anemia Becomes More Common as Kidney Function Declines
Detect and Manage CKD Complications
Complications-metabolic acidosis
Complications-vascular calcification
Hyperkalemia management
Hyperuricemia levels amp CKD
CKD monitoring levels 345
Slide Number 59
When to Refer to a Nephrologist
When to Refer
Steps to CKD Patient Care
Kidney transplantation
Starting Dialysis in the ElderlyhellipOr Not
Ckd management
Case 1
Slide Number 67
Lab results
Slide Number 69
Hypertensive nephropathy with proteinuria
Slide Number 71
Case 2
Slide Number 73
Management of CKD in Diabetes
Case 3
Case 3
Systemic Lupus Erythematosus (SLE)
SLE ndash Lupus Nephritis
Case 5
Case 5
Slide Number 81
Slide Number 82
Case study
Slide Number 84
CXR ndash Hilar Lymphadenopathy
Whats needed next
Slide Number 87
newly dx ckd
Slide Number 89
Bibliography
bibliography
bibliography
bibliography
bibliography
Stage 12
Stage 3
Stage 4
Stage 5
Hb le10 gdL
52
56
11
272
Hb gt10-le12 gdL
216
359
426
483
Hb le12 gdL
267
416
536
755
Stage 12
Stage 3
Stage 4
Stage 5
STATINS-RENOPROTECTIVECONTROVERSY
bull HMG-CoA reductase inhibitors (statins) in high doses can cause proteinuria
bull Possibly associated with less inflammation endothelial dysfunction and scarring in the kidney because they also block inflammatory cytokines
bull Use statins for CV disease not to treat proteinuria
(Afzali and Goldsmith 2016)
MEDICINE CAUTION
bull Hold metformin when gfr lt35 mlmin
bull GFR lt50 mlmin should alert to check all doses of meds
bull No bisphosphanates lt35 mlmin
bull No NSAIDScox 2 inhibitors lt60 mlmin
bull Atenolol ndashrenal excretion
bull BACTRIM A lot of AKI
MEDICINE CAUTION
bull Lovenox-use subcut heparinbull Apixibanbull Dabigatranbull Rivaroxibanbull Lithiumbull GABAPENTIN (ckd 4 max 300mg qd ckd 5 max 300mg qod)
STEPS TO CKD PATIENT CARE
1 CKD definition and risks2 Assess GFR albuminuria3 Determine etiology4 Assess for evidence of progression5 Assess for associated complications6 Discuss dialysistransplantation
CKD-CVD-DIABETES LINK CKD IS A DISEASE MULTIPLIER
National kidney foundation 2014
KDIGO 2017
CKD-MINERAL BONE DISORDERS
bull As kidneys fail they
bull Stop activating calcitriol (the active form of Vit D)mdashcausing calcium imbalance
bull Do not remove phosphorus from bloodmdashleading to phosphorus retention
bull The extra phosphorus pulls calcium out of bones causing them to weaken
bull High phosphorus stimulates PTH release
bull These changes (plus others) cause the start of secondary hyperparathyroidism
bull Labs
bull eGFR
bull Calcium
bull Phos
bull Vit D
bull iPTH
(Qunibi amp Henrich 2017)
PREVALENCE OF ABNORMALITIES OF MINERAL METABOLISM PTH IN CKD
bull Progression of disease ndash declining eGFR increasing proteinuria
bull Degree of proteinuria nephrotic syndrome gt 05-10 gd on ACEi or ARB therapy
bull Etiology of CKD not certain
bull Need help with disease management
bull Indications for kidney biopsy
Rosenberg 2016
WHEN TO REFER
STEPS TO CKD PATIENT CARE
1 CKD definition and risks2 Assess GFR albuminuria3 Determine etiology4 Assess for evidence of progression5 Assess for associated complications6 Discuss dialysistransplantation
KIDNEY TRANSPLANTATION
bull Treatment of choice for ESRDbull Improves quality of lifebull Waiting list time varies-3-5 yearsbull 3 year survival rate after transplantation is 83-94bull Increased risk of cancer
STARTING DIALYSIS IN THE ELDERLYhellipOR NOT
bull Among patients gt 75 yrs with stage 5 CKD who chose to NOT start dialysisbull Overall more likely to die over next 1-2 years bull But if they had ischemic heart disease or other significant comorbidity NO
DIFFERENCE in survival
bull Active disease management and supportive care may be appropriate without starting dialysis in the ill elderly
bull Palliative care does not mean ldquono carerdquo
bull Must have end-of-life discussions
(Murtagh et al 2007)
CKD MANAGEMENTbull Diagnose cause and treat underlying conditionbull Stage per guidelinesbull Slow progression of kidney disease (ACE inhibitors)bull Monitor for complicationsmdashvolume overload hyperkalemia metabolic acidosis
hyperphosphatemia anorexia fatigue htn bone diseasebull Labs cmp cbc phos Vit D 25OH iPTH urine microscopy uric acid urine
proteincr ratio-frequency based off heat map Get sono at least oncebull Vaccinate influenza hep B pneumococcalbull Eval ASCVD risk-likely needs statinbull Possible dexa (donrsquot give bisphosphonates if GFRlt35 let specialist manage)bull Refer to nephrology when eGFR is lt30 (sometimes if higher risk-refer earlier)
CASE 1
bull 55 year old man with past medical history of headaches presents to your office for his first time visit to a PCP in over 30 years
bull He has no past history of being admitted to the hospital and he does not take any OTC medsNSAIDsherbal meds He has no history of ETOH abuse smoking or drug use
bull Vitals BP 180100 mmHg pulse 80 R 18
bull Exam No JVD S1S2 regular PMI shifted to the left no gallop no abdominal bruit pulses bilaterally equal and regular no leg edema
bull What would you order
bull EKG cbc cmp ua urine proteincr ratio lipid
LAB RESULTS
bull Labs reveal a creatinine of 22 mgdL eGFR 33 Urine shows no blood or casts Urineprotein ratio shows 1 gm protein24 hrs EKG shows LVH
bull Next step in workupbull Renal ultrasound 1st then SPEP UPEP with immunofixation serum free light chains
bull Additional labs neg Renal ultrasound shows that both kidneys are slightly reduced in size and are mildly echogenic with no mass or hydronephrosis
bull What is your diagnosis
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileMain_complications_of_persistent_high_blood_pressurepngCreative Commons License associated httpcreativecommonsorglicensesby-sa30
bull 3 months Howevermdashwe have evidence of structural abnormalities Could potentially stage at G3b A3 (red on the heat map)
bull Goal blood pressure
bull JNC 8 14090 NKF 13080
bull Additional lab needed for progression monitoring
bull Cbc renal panel phos Vit D iPTH uric acid urine micro (we already have the renal sono and urine proteincr ratio and lipid)
Selective renal angiography (left lower renal artery) after successful percutaneous balloon dilatation of the stenotic lesionFibromuscular dysplasia in an accessory renal artery causing renovascular hypertension
Secondary Hypertension
Images retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileRenal_FMD2jpg and httpcommonswikimediaorgwikiFileRenal_FMDjpgCreative Commons License associated httpcreativecommonsorglicensesby20deeden (both images)
CASE 2bull OS is a 64year old Hispanic female in for DM check She has had DM for 15+ years and is currently
taking metformin 1000mg bid Lisinopril 10mg a day atorvastatin 40mg a day Labs today showed the following
bull Hgba1c 86 cmp eGFR 50 lipid WNL proteincr ratio 650mg These results are similar to her last visit
bull Upon further hx-you find that she had a recent eye exam and has mild nonproliferaive retinopathy She does not have neuropathy or other ss
bull What further workup do you need
bull Renal sonogram urine micro iPTH vit D (25 OH) phos uric acid
bull Dx stage
bull G3a A3
bull What further treatment do you need
bull Improve glycemic control Increase Lisinopril to 20mg with a goal of 40mg Avoid NSAIDs or other nephrotoxic agents make sure meds are renally dosed monitor 3xyear nephro referral
MANAGEMENT OF CKD IN DIABETESeGFR Recommended
All patients
Yearly measurement of creatinine urinary albumin excretion potassium
45-60 Referral to a nephrologist if possibility for nondiabetickidney disease existsConsider dose adjustment of medicationsMonitor eGFR every 6 monthsMonitor electrolytes bicarbonate hemoglobin calcium phosphorus parathyroid hormone at least yearly
Assure vitamin D sufficiencyConsider bone density testingReferral for dietary counselling
American Diabetes Association Standards of Medical Care in Diabetes Microvascular complications and foot care Diabetes Care 2017 40 (Suppl 1) S88-S98
CASE 3
bull 19 year old African American woman presents to your clinic with complaints of fatigue joint pains a new rash on her face oral ulcer
bull On exam BP 15080 P 88 Afebrile 96 O2 sats on RAbull GEN No respiratory distress at restbull HEENT painless oral ulcer flat rash over malar eminences sparing the nasolabial fold pallor +bull Lungs CTAbull CVS S1S2 regularbull Abdomen soft NTbull Ext left elbow joint and bilateral wrist joints are swollen and tender
bull What would you orderbull CBC CMP ua urine microscopy (microalbumin or urine proteincr ratio) ANA esr RF anti-ccp uric acid TSH
CASE 3
bull Working dx fatigue oral ulcer joint pain
bull Basic Labs Na 135 K 55 Bicarb 18 BUN 50 Cr 35 eGFR 22 Ca 90 ANA + titer 1640
bull UA 3+ blood 3+ protein RBC casts +
bull Given these results what is the most likely diagnosis
bull What would you do
SYSTEMIC LUPUS ERYTHEMATOSUS (SLE)
bull SLE multisystemic disease Etiology unknown
bull Production of autoantibodies and immune complexes formation
bull There is renal involvement in the great majority of patients with SLE at some time of the evolution 66-90
SLE ndash LUPUS NEPHRITIS
bull Race SLE is more commonsevere in African americans than Caucasiansbull
bull Gender female-to-male ratio of 91
bull Age Most patients develop lupus nephritis early in their disease course SLE is more common among women in the third decade of life and lupus nephritis occurs in patients aged 20-40 years
bull Kidney Biopsy For staging lupus nephritis (Class 1-5)
CASE 5bull A 80 year old man who has not seen a PCP in many years
presents to your clinic for weakness for the past few months On further questioning he tells you that his bones also have been hurting lately and he has developed leg swelling in the past month or so
bull On exam bull BP 16090 P 88 Afebrilebull GEN Thin built manbull HEENT pallor presentbull Lungs clearbull CVS S1S2 regular no rub or gallopbull Abdomen soft NTbull Ext 2 + edema
CASE 5
bull Differentials
bull CHF MI Cancer arthritis
bull Labs
bull CBC CMP urine microscopy urine proteincr ratio ESR TSH EKG BNP pa and lat CXR
bull LABS Urine dipstick negative for protein or blood
bull Basic chem bull Na 136 (135-145) K 51 (35-55) Chloride 108 (96-106) Bicarb 25
Given this presentation and the labs (low anion gap and elevated calcium anemia kidney failure) what will you think of What will you order next
Serum and urine protein electrophoresis
Intratubular refractile casts with surrounding syncytial giant cell reaction with chronic tubulointerstitial nephritis and fibrosis characteristic of myeloma cast nephropathy
Kidney Biopsy
CASE STUDYbull A 35 year old African American woman was seen in the clinic for
chronic cough and dyspnea on exertion She gave history of vague symptoms of fatigue and weight loss of 20 Ibs over the last six months
bull List some differentialsbull TB sarcoid lupus thyroid problems PEbull What would you orderbull PPD cbc cmp UA TSH ANA pa and lat cxr
bull Her labs were significant for mildly elevated calcium level and a creatinine of 20 mgdL eGFR 37
bull She had 750 mg of proteinuriaday
bull PPD neg ANA neg TSH and other labs WNL
bull Assuming this is present more than 3 monthshelliphellipwhat is her ckd stage
bull G3b A3
bull What do we still need
CT scan of chest
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileAnterior_mediastinal_mass_thymomajpgCreative Commons License associated httpcreativecommonsorglicensesby20deeden
CXR ndash HILAR LYMPHADENOPATHY
WHATS NEEDED NEXT
bull Biopsy of hilar lymphadenopathy or renal biopsy
bull DX sarcoidosis
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileSarcoidosis_signs_and_symptomsjpgThis work is in the public domain in the United States because it is a work of the United States Federal Government under the terms of Title 17 Chapter 1 Section 105 of the US Code
NEWLY DX CKD
bull 1) urinalysis microscopy ultrasound proteincr ratio
bull If obstruction-treat
bull No obstruction
bull Hx critical (consider myeloma if high risk)
bull glomerular bleeding or albumin in urine
bull Yes workup for glomerular causes (ANArf hep B C upep spep ANCA complement C3 C4)
bull No sterile pyruria-consider interstitial nephritis
bull High risk renovascular disease Evaluate renovascular disease
Additional Online Resources for CKD LearningbullNational Kidney Foundation wwwkidneyorgbullUnited States Renal Data Service wwwusrdsorgbullCDCrsquos CKD Surveillance Project
httpnccdcdcgovckdbullNational Kidney Disease Education Program
(NKDEP) httpnkdepnihgov
BIBLIOGRAPHY
bull Afzali B amp Goldsmith D J (2016 June 29) Statins and chronic kidney disease (G C Curhan amp A M Sheridan Eds) Retrieved 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsstatins-and-chronic-kidney-disease
bull American Diabetes Association Standards of Medical Care in Diabetes (2017) Microvascular complications and foot care Diabetes Care 2017 (40) S88-S98
bull American Diabetes Association Standards of Medical Care in Diabetes (2017) Microvascular complications and foot care Diabetes Care 40 (suppl 1) S88-S98
bull Berns J S (2017 Mar 22) Treatment of anemia in nondialysis chronic kidney disease (T A Golper amp A M Sheridan Eds) Retrieved from UpToDate httpswww-uptodate-comproxywichitaeducontentstreatment-of-anemia-in-nondialysis-chronic-kidney-disease
bull Chan M Dall A T Fletcher K E Lu N amp Trivedi H (2007) Outcomes in patients with chronic kidney disease referred late to nephrologists a meta-analysis American Journal of Medicine 120(12) 1063-1070
bull Coresh J Selvin E amp Stevens L A (2007) Prevalence of chronic kidny disease in the United States JAMA 298(17) doi101001jama298172038
bull de Brito-Ashurst I Varagunam M Raftery M amp Yagoob M (2009) Bicarbonate supplementation slows progression of CKD and improves nutritional status Journal of American Society of Nephrology (20) 2075-2084
BIBLIOGRAPHY
bull Duncan L Heathcoat J Djurdjev O amp Levin A (2001) Screening for renal disease using serum creatinine who are we missing Nephrology Dialysis and Transplant 16(5) 1042-1046
bull Dunkler D Gao P Lee S F Heinz G Clase C M Tobe S Oberbauer R (2015 August 7) Risk prediction for early CKD in type 2 diabetes Retrieved from Clinical Journal of the American Society of Nephrology httpcjasnasnjournalsorgcontent1081371fullsid=61422554-a5f1-41ac-b696-dcd3b12bd268
bull Fatehi P amp Chi-yuan H (September 15 2016) Diagnostic approach to the patient with newly identified chronic kidney disease (G C Curhan amp A M Sheridan Eds) Retrieved May 7 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsdiagnostic-approach-to-the-patient-with-newly-identified-chronic-kidney-disease
bull Fink J e (2009) Chronic Kidney Disease as an Under-Recognized Threat to Patient Safety American journal of kidney diseases the official journal of the National Kidney Foundation 53(4) 681-688
bull Gaffo A L amp Saag K G (2008 Nov) Management of hyperuricemia and gout in CKD doihttpdxdoiorg101053jajkd200807035
bull Hebert L A amp Parikh S V (2014 June 18) Differential diagnosis and evaluation of glomerular disease (R J Glassock amp A Q Lam Eds) Retrieved May 7 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsdifferential-diagnosis-and-evaluation-of-glomerular-disease
bull Inker L Perrone R D Sterns R H amp Forman J P (2017 March 7) Assessment of kidney function Retrieved from UpToDate httpswww-uptodate-comproxywichitaeducontentsassessment-of-kidney-functionsource=search_resultampsearch=creatinineampselectedTitle=1~150
BIBLIOGRAPHY
bull James P A Ortiz E amp Et Al (2014) Evidence based guideline for the management of high blood pressure in adults (JNC) JAMA 311(5) 507-520
bull Kidney Disease Improving Global Outcomes (KDIGO) CKD Work Group (2013 January) KDIGO 2012 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease Retrieved from Kidney International Supplement httpwwwkidney-internationalorg
bull Kunz R Friedrich C Wolbers M amp Mann J F (2008) Meta-analysis effect of monotherapy and combination therapy with inhibitors of the renin angiotensin system on proteinuria in renal disease Annals of Internal Medicine 148(1) 30-48
bull Levey A Stevens L A Schmid C H Castro A F Feldman H I Kusek J W Coresh J (2009) A new equation to estimate glomerular filtration rate Annals of Internal Medicine 150(9) 604-612
bull Levin A Bakris G L Molitch M Smulders M M Williams L A amp Andress D L (2007 Jan) Prevalence of abnormal serum vitamin D PTH calcium and phosphorus in patients with chronic kidney disease results of the study to evaluate early kidney disease Kidney International 71(1) 31-38 Retrieved from PubMED
bull Mahajan A Simoni J Sheather S Broglio K Rajab M amp Wesson D (2010) Daily oral sodium bicarbonate preserves glomerular filtration rate by slowing its decline in early hypertensive nephropathy Kidney International (78_ 303-309
bull Mann J Schmieder R E amp McQueen M (2008) Renal outcomes with telmisartan ramipril or both in people at high vascular risk (the ONTARGET study) a multicentre randomised doubleblind ocntrolled trial Lancet 372(9638) 547-533
BIBLIOGRAPHY
bull Matovinović M S (2009) Pathophysiology and classification of kidney disease Retrieved from The Journal of the International Federation of Clinical Chemistry and Laboratory Medicine httpwwwifccorgifccfilesdocs20010902pdf
bull Moe S Drueke T Lameire N amp Eknoyan G (2007 Jan) Chronic kidney disease-mineral-bone disorder a new paradigmdoi101053jackd200610005
bull Murtagh F E Marsh J E Donohoe P Ekbal N J Sheerin N S amp Harris F E (2007 July) Dialysis or not A comparative survival study of patients over 75 years with chronic kidney disease stage 5 Retrieved from Nephrology Dialysis and Transplant 22(7) httpswwwncbinlmnihgovpubmed17412702
bull National Kidney Foundation (2002) KDOQI clinical practice guidelines for chronic kidney disease evaluation classification andstratification American Journal of Kidney Disease S1-S266
bull National Kidney Foundation (2014 November 5) Fact Sheets Retrieved from httpwwwkidneyorgnewsnewsroomfactsheetsFastFacts
bull Pal S (2012 June 2) Trends in chronic kidney disease Retrieved from US Pharmacist (37)6 httpswwwuspharmacistcomarticletrends-in-chronic-kidney-disease
bull Qunibi W amp Henrich W L (2017 Jan 19) Overview of chronic kidney disease-mineral and bone disorder (J Berns amp A M Sheridan Eds) Retrieved from UpToDate httpswww-uptodate-comoverview-of-chronic-kidney-disease-mineral-and-bone-disorder-ckd-mbd
bull Rosenberg M (2016 Feb 24) Overview of the management of chronic kidney disease in adults (G C Curhan amp A M Sheridan Eds) Retrieved from UpToDate UpToDate httpswww-uptodate-comproxywichitaeducontentsoverview-of-the-management-of-chronic-kidney-disease-in-adults
BIBLIOGRAPHY
bull Szczech L Stewart R C Hsu-Lin S DeLosky R J Astor B C Fox C H Vassalotti J A (2014) Primary care detection of chronic kidney disease in adults with type 2 diabetes The ADD-CKD Study (Awareness Detection and Drug Therapy in type 2 diabetes and chronic kidney disease PLOS doihttpsdoiorg101371journalpone0110535
bull USRDS (2016) Annual data report 2016 Epidemiology of kidney disease in the United States Retrieved from United States Renal Data System httpswwwusrdsorgadraspx
bull Vasudev B amp Vasudev M (2012) A model curriculum for residents rotating in nephrology MedEDPORTAL doihttpdoiorg1015766mep_2374-82658288
bull Wei L MacDonald T M Jennings C Sheng X amp Flynn R W (2013) Estimated GFR reporting is associated with decreased nonsteroidal anti-inflammatory drug prescribing and increased renal function Kidney International (84)1 174-178
chronic kidney disease in primary care
CKD as a Public Health Issue
Slide Number 3
Costs of CKD in 2013 dollarsUSRDS report
Steps to CKD Patient Care
Renal anatomy and physiology
Definition of Chronic Kidney Disease
CKD Risk Factors
Gaps in CKD Diagnosis
Slide Number 10
Steps to CKD Patient Care
creatinine
Glomerular filtration rate
Slide Number 14
Slide Number 15
Use These Equations Cautiously if at all in hellip
lab albumin creatinine ratio
The New CKD Categories
Steps to CKD Patient Care
Slide Number 20
Kidney Involvement in Systemic Diseases
Slide Number 22
Slide Number 23
DysmorphicRenal Hematuria
Slide Number 25
If you have albuminuria or hematuria-order the following labs
Prevalence of Abnormalities of Mineral Metabolism PTH in CKD
Managing CKD-MBD complications
CKD-MBD Testing
Anemia Becomes More Common as Kidney Function Declines
Detect and Manage CKD Complications
Complications-metabolic acidosis
Complications-vascular calcification
Hyperkalemia management
Hyperuricemia levels amp CKD
CKD monitoring levels 345
Slide Number 59
When to Refer to a Nephrologist
When to Refer
Steps to CKD Patient Care
Kidney transplantation
Starting Dialysis in the ElderlyhellipOr Not
Ckd management
Case 1
Slide Number 67
Lab results
Slide Number 69
Hypertensive nephropathy with proteinuria
Slide Number 71
Case 2
Slide Number 73
Management of CKD in Diabetes
Case 3
Case 3
Systemic Lupus Erythematosus (SLE)
SLE ndash Lupus Nephritis
Case 5
Case 5
Slide Number 81
Slide Number 82
Case study
Slide Number 84
CXR ndash Hilar Lymphadenopathy
Whats needed next
Slide Number 87
newly dx ckd
Slide Number 89
Bibliography
bibliography
bibliography
bibliography
bibliography
Stage 12
Stage 3
Stage 4
Stage 5
Hb le10 gdL
52
56
11
272
Hb gt10-le12 gdL
216
359
426
483
Hb le12 gdL
267
416
536
755
Stage 12
Stage 3
Stage 4
Stage 5
MEDICINE CAUTION
bull Hold metformin when gfr lt35 mlmin
bull GFR lt50 mlmin should alert to check all doses of meds
bull No bisphosphanates lt35 mlmin
bull No NSAIDScox 2 inhibitors lt60 mlmin
bull Atenolol ndashrenal excretion
bull BACTRIM A lot of AKI
MEDICINE CAUTION
bull Lovenox-use subcut heparinbull Apixibanbull Dabigatranbull Rivaroxibanbull Lithiumbull GABAPENTIN (ckd 4 max 300mg qd ckd 5 max 300mg qod)
STEPS TO CKD PATIENT CARE
1 CKD definition and risks2 Assess GFR albuminuria3 Determine etiology4 Assess for evidence of progression5 Assess for associated complications6 Discuss dialysistransplantation
CKD-CVD-DIABETES LINK CKD IS A DISEASE MULTIPLIER
National kidney foundation 2014
KDIGO 2017
CKD-MINERAL BONE DISORDERS
bull As kidneys fail they
bull Stop activating calcitriol (the active form of Vit D)mdashcausing calcium imbalance
bull Do not remove phosphorus from bloodmdashleading to phosphorus retention
bull The extra phosphorus pulls calcium out of bones causing them to weaken
bull High phosphorus stimulates PTH release
bull These changes (plus others) cause the start of secondary hyperparathyroidism
bull Labs
bull eGFR
bull Calcium
bull Phos
bull Vit D
bull iPTH
(Qunibi amp Henrich 2017)
PREVALENCE OF ABNORMALITIES OF MINERAL METABOLISM PTH IN CKD
bull Progression of disease ndash declining eGFR increasing proteinuria
bull Degree of proteinuria nephrotic syndrome gt 05-10 gd on ACEi or ARB therapy
bull Etiology of CKD not certain
bull Need help with disease management
bull Indications for kidney biopsy
Rosenberg 2016
WHEN TO REFER
STEPS TO CKD PATIENT CARE
1 CKD definition and risks2 Assess GFR albuminuria3 Determine etiology4 Assess for evidence of progression5 Assess for associated complications6 Discuss dialysistransplantation
KIDNEY TRANSPLANTATION
bull Treatment of choice for ESRDbull Improves quality of lifebull Waiting list time varies-3-5 yearsbull 3 year survival rate after transplantation is 83-94bull Increased risk of cancer
STARTING DIALYSIS IN THE ELDERLYhellipOR NOT
bull Among patients gt 75 yrs with stage 5 CKD who chose to NOT start dialysisbull Overall more likely to die over next 1-2 years bull But if they had ischemic heart disease or other significant comorbidity NO
DIFFERENCE in survival
bull Active disease management and supportive care may be appropriate without starting dialysis in the ill elderly
bull Palliative care does not mean ldquono carerdquo
bull Must have end-of-life discussions
(Murtagh et al 2007)
CKD MANAGEMENTbull Diagnose cause and treat underlying conditionbull Stage per guidelinesbull Slow progression of kidney disease (ACE inhibitors)bull Monitor for complicationsmdashvolume overload hyperkalemia metabolic acidosis
hyperphosphatemia anorexia fatigue htn bone diseasebull Labs cmp cbc phos Vit D 25OH iPTH urine microscopy uric acid urine
proteincr ratio-frequency based off heat map Get sono at least oncebull Vaccinate influenza hep B pneumococcalbull Eval ASCVD risk-likely needs statinbull Possible dexa (donrsquot give bisphosphonates if GFRlt35 let specialist manage)bull Refer to nephrology when eGFR is lt30 (sometimes if higher risk-refer earlier)
CASE 1
bull 55 year old man with past medical history of headaches presents to your office for his first time visit to a PCP in over 30 years
bull He has no past history of being admitted to the hospital and he does not take any OTC medsNSAIDsherbal meds He has no history of ETOH abuse smoking or drug use
bull Vitals BP 180100 mmHg pulse 80 R 18
bull Exam No JVD S1S2 regular PMI shifted to the left no gallop no abdominal bruit pulses bilaterally equal and regular no leg edema
bull What would you order
bull EKG cbc cmp ua urine proteincr ratio lipid
LAB RESULTS
bull Labs reveal a creatinine of 22 mgdL eGFR 33 Urine shows no blood or casts Urineprotein ratio shows 1 gm protein24 hrs EKG shows LVH
bull Next step in workupbull Renal ultrasound 1st then SPEP UPEP with immunofixation serum free light chains
bull Additional labs neg Renal ultrasound shows that both kidneys are slightly reduced in size and are mildly echogenic with no mass or hydronephrosis
bull What is your diagnosis
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileMain_complications_of_persistent_high_blood_pressurepngCreative Commons License associated httpcreativecommonsorglicensesby-sa30
bull 3 months Howevermdashwe have evidence of structural abnormalities Could potentially stage at G3b A3 (red on the heat map)
bull Goal blood pressure
bull JNC 8 14090 NKF 13080
bull Additional lab needed for progression monitoring
bull Cbc renal panel phos Vit D iPTH uric acid urine micro (we already have the renal sono and urine proteincr ratio and lipid)
Selective renal angiography (left lower renal artery) after successful percutaneous balloon dilatation of the stenotic lesionFibromuscular dysplasia in an accessory renal artery causing renovascular hypertension
Secondary Hypertension
Images retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileRenal_FMD2jpg and httpcommonswikimediaorgwikiFileRenal_FMDjpgCreative Commons License associated httpcreativecommonsorglicensesby20deeden (both images)
CASE 2bull OS is a 64year old Hispanic female in for DM check She has had DM for 15+ years and is currently
taking metformin 1000mg bid Lisinopril 10mg a day atorvastatin 40mg a day Labs today showed the following
bull Hgba1c 86 cmp eGFR 50 lipid WNL proteincr ratio 650mg These results are similar to her last visit
bull Upon further hx-you find that she had a recent eye exam and has mild nonproliferaive retinopathy She does not have neuropathy or other ss
bull What further workup do you need
bull Renal sonogram urine micro iPTH vit D (25 OH) phos uric acid
bull Dx stage
bull G3a A3
bull What further treatment do you need
bull Improve glycemic control Increase Lisinopril to 20mg with a goal of 40mg Avoid NSAIDs or other nephrotoxic agents make sure meds are renally dosed monitor 3xyear nephro referral
MANAGEMENT OF CKD IN DIABETESeGFR Recommended
All patients
Yearly measurement of creatinine urinary albumin excretion potassium
45-60 Referral to a nephrologist if possibility for nondiabetickidney disease existsConsider dose adjustment of medicationsMonitor eGFR every 6 monthsMonitor electrolytes bicarbonate hemoglobin calcium phosphorus parathyroid hormone at least yearly
Assure vitamin D sufficiencyConsider bone density testingReferral for dietary counselling
American Diabetes Association Standards of Medical Care in Diabetes Microvascular complications and foot care Diabetes Care 2017 40 (Suppl 1) S88-S98
CASE 3
bull 19 year old African American woman presents to your clinic with complaints of fatigue joint pains a new rash on her face oral ulcer
bull On exam BP 15080 P 88 Afebrile 96 O2 sats on RAbull GEN No respiratory distress at restbull HEENT painless oral ulcer flat rash over malar eminences sparing the nasolabial fold pallor +bull Lungs CTAbull CVS S1S2 regularbull Abdomen soft NTbull Ext left elbow joint and bilateral wrist joints are swollen and tender
bull What would you orderbull CBC CMP ua urine microscopy (microalbumin or urine proteincr ratio) ANA esr RF anti-ccp uric acid TSH
CASE 3
bull Working dx fatigue oral ulcer joint pain
bull Basic Labs Na 135 K 55 Bicarb 18 BUN 50 Cr 35 eGFR 22 Ca 90 ANA + titer 1640
bull UA 3+ blood 3+ protein RBC casts +
bull Given these results what is the most likely diagnosis
bull What would you do
SYSTEMIC LUPUS ERYTHEMATOSUS (SLE)
bull SLE multisystemic disease Etiology unknown
bull Production of autoantibodies and immune complexes formation
bull There is renal involvement in the great majority of patients with SLE at some time of the evolution 66-90
SLE ndash LUPUS NEPHRITIS
bull Race SLE is more commonsevere in African americans than Caucasiansbull
bull Gender female-to-male ratio of 91
bull Age Most patients develop lupus nephritis early in their disease course SLE is more common among women in the third decade of life and lupus nephritis occurs in patients aged 20-40 years
bull Kidney Biopsy For staging lupus nephritis (Class 1-5)
CASE 5bull A 80 year old man who has not seen a PCP in many years
presents to your clinic for weakness for the past few months On further questioning he tells you that his bones also have been hurting lately and he has developed leg swelling in the past month or so
bull On exam bull BP 16090 P 88 Afebrilebull GEN Thin built manbull HEENT pallor presentbull Lungs clearbull CVS S1S2 regular no rub or gallopbull Abdomen soft NTbull Ext 2 + edema
CASE 5
bull Differentials
bull CHF MI Cancer arthritis
bull Labs
bull CBC CMP urine microscopy urine proteincr ratio ESR TSH EKG BNP pa and lat CXR
bull LABS Urine dipstick negative for protein or blood
bull Basic chem bull Na 136 (135-145) K 51 (35-55) Chloride 108 (96-106) Bicarb 25
Given this presentation and the labs (low anion gap and elevated calcium anemia kidney failure) what will you think of What will you order next
Serum and urine protein electrophoresis
Intratubular refractile casts with surrounding syncytial giant cell reaction with chronic tubulointerstitial nephritis and fibrosis characteristic of myeloma cast nephropathy
Kidney Biopsy
CASE STUDYbull A 35 year old African American woman was seen in the clinic for
chronic cough and dyspnea on exertion She gave history of vague symptoms of fatigue and weight loss of 20 Ibs over the last six months
bull List some differentialsbull TB sarcoid lupus thyroid problems PEbull What would you orderbull PPD cbc cmp UA TSH ANA pa and lat cxr
bull Her labs were significant for mildly elevated calcium level and a creatinine of 20 mgdL eGFR 37
bull She had 750 mg of proteinuriaday
bull PPD neg ANA neg TSH and other labs WNL
bull Assuming this is present more than 3 monthshelliphellipwhat is her ckd stage
bull G3b A3
bull What do we still need
CT scan of chest
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileAnterior_mediastinal_mass_thymomajpgCreative Commons License associated httpcreativecommonsorglicensesby20deeden
CXR ndash HILAR LYMPHADENOPATHY
WHATS NEEDED NEXT
bull Biopsy of hilar lymphadenopathy or renal biopsy
bull DX sarcoidosis
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileSarcoidosis_signs_and_symptomsjpgThis work is in the public domain in the United States because it is a work of the United States Federal Government under the terms of Title 17 Chapter 1 Section 105 of the US Code
NEWLY DX CKD
bull 1) urinalysis microscopy ultrasound proteincr ratio
bull If obstruction-treat
bull No obstruction
bull Hx critical (consider myeloma if high risk)
bull glomerular bleeding or albumin in urine
bull Yes workup for glomerular causes (ANArf hep B C upep spep ANCA complement C3 C4)
bull No sterile pyruria-consider interstitial nephritis
bull High risk renovascular disease Evaluate renovascular disease
Additional Online Resources for CKD LearningbullNational Kidney Foundation wwwkidneyorgbullUnited States Renal Data Service wwwusrdsorgbullCDCrsquos CKD Surveillance Project
httpnccdcdcgovckdbullNational Kidney Disease Education Program
(NKDEP) httpnkdepnihgov
BIBLIOGRAPHY
bull Afzali B amp Goldsmith D J (2016 June 29) Statins and chronic kidney disease (G C Curhan amp A M Sheridan Eds) Retrieved 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsstatins-and-chronic-kidney-disease
bull American Diabetes Association Standards of Medical Care in Diabetes (2017) Microvascular complications and foot care Diabetes Care 2017 (40) S88-S98
bull American Diabetes Association Standards of Medical Care in Diabetes (2017) Microvascular complications and foot care Diabetes Care 40 (suppl 1) S88-S98
bull Berns J S (2017 Mar 22) Treatment of anemia in nondialysis chronic kidney disease (T A Golper amp A M Sheridan Eds) Retrieved from UpToDate httpswww-uptodate-comproxywichitaeducontentstreatment-of-anemia-in-nondialysis-chronic-kidney-disease
bull Chan M Dall A T Fletcher K E Lu N amp Trivedi H (2007) Outcomes in patients with chronic kidney disease referred late to nephrologists a meta-analysis American Journal of Medicine 120(12) 1063-1070
bull Coresh J Selvin E amp Stevens L A (2007) Prevalence of chronic kidny disease in the United States JAMA 298(17) doi101001jama298172038
bull de Brito-Ashurst I Varagunam M Raftery M amp Yagoob M (2009) Bicarbonate supplementation slows progression of CKD and improves nutritional status Journal of American Society of Nephrology (20) 2075-2084
BIBLIOGRAPHY
bull Duncan L Heathcoat J Djurdjev O amp Levin A (2001) Screening for renal disease using serum creatinine who are we missing Nephrology Dialysis and Transplant 16(5) 1042-1046
bull Dunkler D Gao P Lee S F Heinz G Clase C M Tobe S Oberbauer R (2015 August 7) Risk prediction for early CKD in type 2 diabetes Retrieved from Clinical Journal of the American Society of Nephrology httpcjasnasnjournalsorgcontent1081371fullsid=61422554-a5f1-41ac-b696-dcd3b12bd268
bull Fatehi P amp Chi-yuan H (September 15 2016) Diagnostic approach to the patient with newly identified chronic kidney disease (G C Curhan amp A M Sheridan Eds) Retrieved May 7 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsdiagnostic-approach-to-the-patient-with-newly-identified-chronic-kidney-disease
bull Fink J e (2009) Chronic Kidney Disease as an Under-Recognized Threat to Patient Safety American journal of kidney diseases the official journal of the National Kidney Foundation 53(4) 681-688
bull Gaffo A L amp Saag K G (2008 Nov) Management of hyperuricemia and gout in CKD doihttpdxdoiorg101053jajkd200807035
bull Hebert L A amp Parikh S V (2014 June 18) Differential diagnosis and evaluation of glomerular disease (R J Glassock amp A Q Lam Eds) Retrieved May 7 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsdifferential-diagnosis-and-evaluation-of-glomerular-disease
bull Inker L Perrone R D Sterns R H amp Forman J P (2017 March 7) Assessment of kidney function Retrieved from UpToDate httpswww-uptodate-comproxywichitaeducontentsassessment-of-kidney-functionsource=search_resultampsearch=creatinineampselectedTitle=1~150
BIBLIOGRAPHY
bull James P A Ortiz E amp Et Al (2014) Evidence based guideline for the management of high blood pressure in adults (JNC) JAMA 311(5) 507-520
bull Kidney Disease Improving Global Outcomes (KDIGO) CKD Work Group (2013 January) KDIGO 2012 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease Retrieved from Kidney International Supplement httpwwwkidney-internationalorg
bull Kunz R Friedrich C Wolbers M amp Mann J F (2008) Meta-analysis effect of monotherapy and combination therapy with inhibitors of the renin angiotensin system on proteinuria in renal disease Annals of Internal Medicine 148(1) 30-48
bull Levey A Stevens L A Schmid C H Castro A F Feldman H I Kusek J W Coresh J (2009) A new equation to estimate glomerular filtration rate Annals of Internal Medicine 150(9) 604-612
bull Levin A Bakris G L Molitch M Smulders M M Williams L A amp Andress D L (2007 Jan) Prevalence of abnormal serum vitamin D PTH calcium and phosphorus in patients with chronic kidney disease results of the study to evaluate early kidney disease Kidney International 71(1) 31-38 Retrieved from PubMED
bull Mahajan A Simoni J Sheather S Broglio K Rajab M amp Wesson D (2010) Daily oral sodium bicarbonate preserves glomerular filtration rate by slowing its decline in early hypertensive nephropathy Kidney International (78_ 303-309
bull Mann J Schmieder R E amp McQueen M (2008) Renal outcomes with telmisartan ramipril or both in people at high vascular risk (the ONTARGET study) a multicentre randomised doubleblind ocntrolled trial Lancet 372(9638) 547-533
BIBLIOGRAPHY
bull Matovinović M S (2009) Pathophysiology and classification of kidney disease Retrieved from The Journal of the International Federation of Clinical Chemistry and Laboratory Medicine httpwwwifccorgifccfilesdocs20010902pdf
bull Moe S Drueke T Lameire N amp Eknoyan G (2007 Jan) Chronic kidney disease-mineral-bone disorder a new paradigmdoi101053jackd200610005
bull Murtagh F E Marsh J E Donohoe P Ekbal N J Sheerin N S amp Harris F E (2007 July) Dialysis or not A comparative survival study of patients over 75 years with chronic kidney disease stage 5 Retrieved from Nephrology Dialysis and Transplant 22(7) httpswwwncbinlmnihgovpubmed17412702
bull National Kidney Foundation (2002) KDOQI clinical practice guidelines for chronic kidney disease evaluation classification andstratification American Journal of Kidney Disease S1-S266
bull National Kidney Foundation (2014 November 5) Fact Sheets Retrieved from httpwwwkidneyorgnewsnewsroomfactsheetsFastFacts
bull Pal S (2012 June 2) Trends in chronic kidney disease Retrieved from US Pharmacist (37)6 httpswwwuspharmacistcomarticletrends-in-chronic-kidney-disease
bull Qunibi W amp Henrich W L (2017 Jan 19) Overview of chronic kidney disease-mineral and bone disorder (J Berns amp A M Sheridan Eds) Retrieved from UpToDate httpswww-uptodate-comoverview-of-chronic-kidney-disease-mineral-and-bone-disorder-ckd-mbd
bull Rosenberg M (2016 Feb 24) Overview of the management of chronic kidney disease in adults (G C Curhan amp A M Sheridan Eds) Retrieved from UpToDate UpToDate httpswww-uptodate-comproxywichitaeducontentsoverview-of-the-management-of-chronic-kidney-disease-in-adults
BIBLIOGRAPHY
bull Szczech L Stewart R C Hsu-Lin S DeLosky R J Astor B C Fox C H Vassalotti J A (2014) Primary care detection of chronic kidney disease in adults with type 2 diabetes The ADD-CKD Study (Awareness Detection and Drug Therapy in type 2 diabetes and chronic kidney disease PLOS doihttpsdoiorg101371journalpone0110535
bull USRDS (2016) Annual data report 2016 Epidemiology of kidney disease in the United States Retrieved from United States Renal Data System httpswwwusrdsorgadraspx
bull Vasudev B amp Vasudev M (2012) A model curriculum for residents rotating in nephrology MedEDPORTAL doihttpdoiorg1015766mep_2374-82658288
bull Wei L MacDonald T M Jennings C Sheng X amp Flynn R W (2013) Estimated GFR reporting is associated with decreased nonsteroidal anti-inflammatory drug prescribing and increased renal function Kidney International (84)1 174-178
chronic kidney disease in primary care
CKD as a Public Health Issue
Slide Number 3
Costs of CKD in 2013 dollarsUSRDS report
Steps to CKD Patient Care
Renal anatomy and physiology
Definition of Chronic Kidney Disease
CKD Risk Factors
Gaps in CKD Diagnosis
Slide Number 10
Steps to CKD Patient Care
creatinine
Glomerular filtration rate
Slide Number 14
Slide Number 15
Use These Equations Cautiously if at all in hellip
lab albumin creatinine ratio
The New CKD Categories
Steps to CKD Patient Care
Slide Number 20
Kidney Involvement in Systemic Diseases
Slide Number 22
Slide Number 23
DysmorphicRenal Hematuria
Slide Number 25
If you have albuminuria or hematuria-order the following labs
Prevalence of Abnormalities of Mineral Metabolism PTH in CKD
Managing CKD-MBD complications
CKD-MBD Testing
Anemia Becomes More Common as Kidney Function Declines
Detect and Manage CKD Complications
Complications-metabolic acidosis
Complications-vascular calcification
Hyperkalemia management
Hyperuricemia levels amp CKD
CKD monitoring levels 345
Slide Number 59
When to Refer to a Nephrologist
When to Refer
Steps to CKD Patient Care
Kidney transplantation
Starting Dialysis in the ElderlyhellipOr Not
Ckd management
Case 1
Slide Number 67
Lab results
Slide Number 69
Hypertensive nephropathy with proteinuria
Slide Number 71
Case 2
Slide Number 73
Management of CKD in Diabetes
Case 3
Case 3
Systemic Lupus Erythematosus (SLE)
SLE ndash Lupus Nephritis
Case 5
Case 5
Slide Number 81
Slide Number 82
Case study
Slide Number 84
CXR ndash Hilar Lymphadenopathy
Whats needed next
Slide Number 87
newly dx ckd
Slide Number 89
Bibliography
bibliography
bibliography
bibliography
bibliography
Stage 12
Stage 3
Stage 4
Stage 5
Hb le10 gdL
52
56
11
272
Hb gt10-le12 gdL
216
359
426
483
Hb le12 gdL
267
416
536
755
Stage 12
Stage 3
Stage 4
Stage 5
MEDICINE CAUTION
bull Lovenox-use subcut heparinbull Apixibanbull Dabigatranbull Rivaroxibanbull Lithiumbull GABAPENTIN (ckd 4 max 300mg qd ckd 5 max 300mg qod)
STEPS TO CKD PATIENT CARE
1 CKD definition and risks2 Assess GFR albuminuria3 Determine etiology4 Assess for evidence of progression5 Assess for associated complications6 Discuss dialysistransplantation
CKD-CVD-DIABETES LINK CKD IS A DISEASE MULTIPLIER
National kidney foundation 2014
KDIGO 2017
CKD-MINERAL BONE DISORDERS
bull As kidneys fail they
bull Stop activating calcitriol (the active form of Vit D)mdashcausing calcium imbalance
bull Do not remove phosphorus from bloodmdashleading to phosphorus retention
bull The extra phosphorus pulls calcium out of bones causing them to weaken
bull High phosphorus stimulates PTH release
bull These changes (plus others) cause the start of secondary hyperparathyroidism
bull Labs
bull eGFR
bull Calcium
bull Phos
bull Vit D
bull iPTH
(Qunibi amp Henrich 2017)
PREVALENCE OF ABNORMALITIES OF MINERAL METABOLISM PTH IN CKD
bull Progression of disease ndash declining eGFR increasing proteinuria
bull Degree of proteinuria nephrotic syndrome gt 05-10 gd on ACEi or ARB therapy
bull Etiology of CKD not certain
bull Need help with disease management
bull Indications for kidney biopsy
Rosenberg 2016
WHEN TO REFER
STEPS TO CKD PATIENT CARE
1 CKD definition and risks2 Assess GFR albuminuria3 Determine etiology4 Assess for evidence of progression5 Assess for associated complications6 Discuss dialysistransplantation
KIDNEY TRANSPLANTATION
bull Treatment of choice for ESRDbull Improves quality of lifebull Waiting list time varies-3-5 yearsbull 3 year survival rate after transplantation is 83-94bull Increased risk of cancer
STARTING DIALYSIS IN THE ELDERLYhellipOR NOT
bull Among patients gt 75 yrs with stage 5 CKD who chose to NOT start dialysisbull Overall more likely to die over next 1-2 years bull But if they had ischemic heart disease or other significant comorbidity NO
DIFFERENCE in survival
bull Active disease management and supportive care may be appropriate without starting dialysis in the ill elderly
bull Palliative care does not mean ldquono carerdquo
bull Must have end-of-life discussions
(Murtagh et al 2007)
CKD MANAGEMENTbull Diagnose cause and treat underlying conditionbull Stage per guidelinesbull Slow progression of kidney disease (ACE inhibitors)bull Monitor for complicationsmdashvolume overload hyperkalemia metabolic acidosis
hyperphosphatemia anorexia fatigue htn bone diseasebull Labs cmp cbc phos Vit D 25OH iPTH urine microscopy uric acid urine
proteincr ratio-frequency based off heat map Get sono at least oncebull Vaccinate influenza hep B pneumococcalbull Eval ASCVD risk-likely needs statinbull Possible dexa (donrsquot give bisphosphonates if GFRlt35 let specialist manage)bull Refer to nephrology when eGFR is lt30 (sometimes if higher risk-refer earlier)
CASE 1
bull 55 year old man with past medical history of headaches presents to your office for his first time visit to a PCP in over 30 years
bull He has no past history of being admitted to the hospital and he does not take any OTC medsNSAIDsherbal meds He has no history of ETOH abuse smoking or drug use
bull Vitals BP 180100 mmHg pulse 80 R 18
bull Exam No JVD S1S2 regular PMI shifted to the left no gallop no abdominal bruit pulses bilaterally equal and regular no leg edema
bull What would you order
bull EKG cbc cmp ua urine proteincr ratio lipid
LAB RESULTS
bull Labs reveal a creatinine of 22 mgdL eGFR 33 Urine shows no blood or casts Urineprotein ratio shows 1 gm protein24 hrs EKG shows LVH
bull Next step in workupbull Renal ultrasound 1st then SPEP UPEP with immunofixation serum free light chains
bull Additional labs neg Renal ultrasound shows that both kidneys are slightly reduced in size and are mildly echogenic with no mass or hydronephrosis
bull What is your diagnosis
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileMain_complications_of_persistent_high_blood_pressurepngCreative Commons License associated httpcreativecommonsorglicensesby-sa30
bull 3 months Howevermdashwe have evidence of structural abnormalities Could potentially stage at G3b A3 (red on the heat map)
bull Goal blood pressure
bull JNC 8 14090 NKF 13080
bull Additional lab needed for progression monitoring
bull Cbc renal panel phos Vit D iPTH uric acid urine micro (we already have the renal sono and urine proteincr ratio and lipid)
Selective renal angiography (left lower renal artery) after successful percutaneous balloon dilatation of the stenotic lesionFibromuscular dysplasia in an accessory renal artery causing renovascular hypertension
Secondary Hypertension
Images retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileRenal_FMD2jpg and httpcommonswikimediaorgwikiFileRenal_FMDjpgCreative Commons License associated httpcreativecommonsorglicensesby20deeden (both images)
CASE 2bull OS is a 64year old Hispanic female in for DM check She has had DM for 15+ years and is currently
taking metformin 1000mg bid Lisinopril 10mg a day atorvastatin 40mg a day Labs today showed the following
bull Hgba1c 86 cmp eGFR 50 lipid WNL proteincr ratio 650mg These results are similar to her last visit
bull Upon further hx-you find that she had a recent eye exam and has mild nonproliferaive retinopathy She does not have neuropathy or other ss
bull What further workup do you need
bull Renal sonogram urine micro iPTH vit D (25 OH) phos uric acid
bull Dx stage
bull G3a A3
bull What further treatment do you need
bull Improve glycemic control Increase Lisinopril to 20mg with a goal of 40mg Avoid NSAIDs or other nephrotoxic agents make sure meds are renally dosed monitor 3xyear nephro referral
MANAGEMENT OF CKD IN DIABETESeGFR Recommended
All patients
Yearly measurement of creatinine urinary albumin excretion potassium
45-60 Referral to a nephrologist if possibility for nondiabetickidney disease existsConsider dose adjustment of medicationsMonitor eGFR every 6 monthsMonitor electrolytes bicarbonate hemoglobin calcium phosphorus parathyroid hormone at least yearly
Assure vitamin D sufficiencyConsider bone density testingReferral for dietary counselling
American Diabetes Association Standards of Medical Care in Diabetes Microvascular complications and foot care Diabetes Care 2017 40 (Suppl 1) S88-S98
CASE 3
bull 19 year old African American woman presents to your clinic with complaints of fatigue joint pains a new rash on her face oral ulcer
bull On exam BP 15080 P 88 Afebrile 96 O2 sats on RAbull GEN No respiratory distress at restbull HEENT painless oral ulcer flat rash over malar eminences sparing the nasolabial fold pallor +bull Lungs CTAbull CVS S1S2 regularbull Abdomen soft NTbull Ext left elbow joint and bilateral wrist joints are swollen and tender
bull What would you orderbull CBC CMP ua urine microscopy (microalbumin or urine proteincr ratio) ANA esr RF anti-ccp uric acid TSH
CASE 3
bull Working dx fatigue oral ulcer joint pain
bull Basic Labs Na 135 K 55 Bicarb 18 BUN 50 Cr 35 eGFR 22 Ca 90 ANA + titer 1640
bull UA 3+ blood 3+ protein RBC casts +
bull Given these results what is the most likely diagnosis
bull What would you do
SYSTEMIC LUPUS ERYTHEMATOSUS (SLE)
bull SLE multisystemic disease Etiology unknown
bull Production of autoantibodies and immune complexes formation
bull There is renal involvement in the great majority of patients with SLE at some time of the evolution 66-90
SLE ndash LUPUS NEPHRITIS
bull Race SLE is more commonsevere in African americans than Caucasiansbull
bull Gender female-to-male ratio of 91
bull Age Most patients develop lupus nephritis early in their disease course SLE is more common among women in the third decade of life and lupus nephritis occurs in patients aged 20-40 years
bull Kidney Biopsy For staging lupus nephritis (Class 1-5)
CASE 5bull A 80 year old man who has not seen a PCP in many years
presents to your clinic for weakness for the past few months On further questioning he tells you that his bones also have been hurting lately and he has developed leg swelling in the past month or so
bull On exam bull BP 16090 P 88 Afebrilebull GEN Thin built manbull HEENT pallor presentbull Lungs clearbull CVS S1S2 regular no rub or gallopbull Abdomen soft NTbull Ext 2 + edema
CASE 5
bull Differentials
bull CHF MI Cancer arthritis
bull Labs
bull CBC CMP urine microscopy urine proteincr ratio ESR TSH EKG BNP pa and lat CXR
bull LABS Urine dipstick negative for protein or blood
bull Basic chem bull Na 136 (135-145) K 51 (35-55) Chloride 108 (96-106) Bicarb 25
Given this presentation and the labs (low anion gap and elevated calcium anemia kidney failure) what will you think of What will you order next
Serum and urine protein electrophoresis
Intratubular refractile casts with surrounding syncytial giant cell reaction with chronic tubulointerstitial nephritis and fibrosis characteristic of myeloma cast nephropathy
Kidney Biopsy
CASE STUDYbull A 35 year old African American woman was seen in the clinic for
chronic cough and dyspnea on exertion She gave history of vague symptoms of fatigue and weight loss of 20 Ibs over the last six months
bull List some differentialsbull TB sarcoid lupus thyroid problems PEbull What would you orderbull PPD cbc cmp UA TSH ANA pa and lat cxr
bull Her labs were significant for mildly elevated calcium level and a creatinine of 20 mgdL eGFR 37
bull She had 750 mg of proteinuriaday
bull PPD neg ANA neg TSH and other labs WNL
bull Assuming this is present more than 3 monthshelliphellipwhat is her ckd stage
bull G3b A3
bull What do we still need
CT scan of chest
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileAnterior_mediastinal_mass_thymomajpgCreative Commons License associated httpcreativecommonsorglicensesby20deeden
CXR ndash HILAR LYMPHADENOPATHY
WHATS NEEDED NEXT
bull Biopsy of hilar lymphadenopathy or renal biopsy
bull DX sarcoidosis
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileSarcoidosis_signs_and_symptomsjpgThis work is in the public domain in the United States because it is a work of the United States Federal Government under the terms of Title 17 Chapter 1 Section 105 of the US Code
NEWLY DX CKD
bull 1) urinalysis microscopy ultrasound proteincr ratio
bull If obstruction-treat
bull No obstruction
bull Hx critical (consider myeloma if high risk)
bull glomerular bleeding or albumin in urine
bull Yes workup for glomerular causes (ANArf hep B C upep spep ANCA complement C3 C4)
bull No sterile pyruria-consider interstitial nephritis
bull High risk renovascular disease Evaluate renovascular disease
Additional Online Resources for CKD LearningbullNational Kidney Foundation wwwkidneyorgbullUnited States Renal Data Service wwwusrdsorgbullCDCrsquos CKD Surveillance Project
httpnccdcdcgovckdbullNational Kidney Disease Education Program
(NKDEP) httpnkdepnihgov
BIBLIOGRAPHY
bull Afzali B amp Goldsmith D J (2016 June 29) Statins and chronic kidney disease (G C Curhan amp A M Sheridan Eds) Retrieved 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsstatins-and-chronic-kidney-disease
bull American Diabetes Association Standards of Medical Care in Diabetes (2017) Microvascular complications and foot care Diabetes Care 2017 (40) S88-S98
bull American Diabetes Association Standards of Medical Care in Diabetes (2017) Microvascular complications and foot care Diabetes Care 40 (suppl 1) S88-S98
bull Berns J S (2017 Mar 22) Treatment of anemia in nondialysis chronic kidney disease (T A Golper amp A M Sheridan Eds) Retrieved from UpToDate httpswww-uptodate-comproxywichitaeducontentstreatment-of-anemia-in-nondialysis-chronic-kidney-disease
bull Chan M Dall A T Fletcher K E Lu N amp Trivedi H (2007) Outcomes in patients with chronic kidney disease referred late to nephrologists a meta-analysis American Journal of Medicine 120(12) 1063-1070
bull Coresh J Selvin E amp Stevens L A (2007) Prevalence of chronic kidny disease in the United States JAMA 298(17) doi101001jama298172038
bull de Brito-Ashurst I Varagunam M Raftery M amp Yagoob M (2009) Bicarbonate supplementation slows progression of CKD and improves nutritional status Journal of American Society of Nephrology (20) 2075-2084
BIBLIOGRAPHY
bull Duncan L Heathcoat J Djurdjev O amp Levin A (2001) Screening for renal disease using serum creatinine who are we missing Nephrology Dialysis and Transplant 16(5) 1042-1046
bull Dunkler D Gao P Lee S F Heinz G Clase C M Tobe S Oberbauer R (2015 August 7) Risk prediction for early CKD in type 2 diabetes Retrieved from Clinical Journal of the American Society of Nephrology httpcjasnasnjournalsorgcontent1081371fullsid=61422554-a5f1-41ac-b696-dcd3b12bd268
bull Fatehi P amp Chi-yuan H (September 15 2016) Diagnostic approach to the patient with newly identified chronic kidney disease (G C Curhan amp A M Sheridan Eds) Retrieved May 7 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsdiagnostic-approach-to-the-patient-with-newly-identified-chronic-kidney-disease
bull Fink J e (2009) Chronic Kidney Disease as an Under-Recognized Threat to Patient Safety American journal of kidney diseases the official journal of the National Kidney Foundation 53(4) 681-688
bull Gaffo A L amp Saag K G (2008 Nov) Management of hyperuricemia and gout in CKD doihttpdxdoiorg101053jajkd200807035
bull Hebert L A amp Parikh S V (2014 June 18) Differential diagnosis and evaluation of glomerular disease (R J Glassock amp A Q Lam Eds) Retrieved May 7 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsdifferential-diagnosis-and-evaluation-of-glomerular-disease
bull Inker L Perrone R D Sterns R H amp Forman J P (2017 March 7) Assessment of kidney function Retrieved from UpToDate httpswww-uptodate-comproxywichitaeducontentsassessment-of-kidney-functionsource=search_resultampsearch=creatinineampselectedTitle=1~150
BIBLIOGRAPHY
bull James P A Ortiz E amp Et Al (2014) Evidence based guideline for the management of high blood pressure in adults (JNC) JAMA 311(5) 507-520
bull Kidney Disease Improving Global Outcomes (KDIGO) CKD Work Group (2013 January) KDIGO 2012 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease Retrieved from Kidney International Supplement httpwwwkidney-internationalorg
bull Kunz R Friedrich C Wolbers M amp Mann J F (2008) Meta-analysis effect of monotherapy and combination therapy with inhibitors of the renin angiotensin system on proteinuria in renal disease Annals of Internal Medicine 148(1) 30-48
bull Levey A Stevens L A Schmid C H Castro A F Feldman H I Kusek J W Coresh J (2009) A new equation to estimate glomerular filtration rate Annals of Internal Medicine 150(9) 604-612
bull Levin A Bakris G L Molitch M Smulders M M Williams L A amp Andress D L (2007 Jan) Prevalence of abnormal serum vitamin D PTH calcium and phosphorus in patients with chronic kidney disease results of the study to evaluate early kidney disease Kidney International 71(1) 31-38 Retrieved from PubMED
bull Mahajan A Simoni J Sheather S Broglio K Rajab M amp Wesson D (2010) Daily oral sodium bicarbonate preserves glomerular filtration rate by slowing its decline in early hypertensive nephropathy Kidney International (78_ 303-309
bull Mann J Schmieder R E amp McQueen M (2008) Renal outcomes with telmisartan ramipril or both in people at high vascular risk (the ONTARGET study) a multicentre randomised doubleblind ocntrolled trial Lancet 372(9638) 547-533
BIBLIOGRAPHY
bull Matovinović M S (2009) Pathophysiology and classification of kidney disease Retrieved from The Journal of the International Federation of Clinical Chemistry and Laboratory Medicine httpwwwifccorgifccfilesdocs20010902pdf
bull Moe S Drueke T Lameire N amp Eknoyan G (2007 Jan) Chronic kidney disease-mineral-bone disorder a new paradigmdoi101053jackd200610005
bull Murtagh F E Marsh J E Donohoe P Ekbal N J Sheerin N S amp Harris F E (2007 July) Dialysis or not A comparative survival study of patients over 75 years with chronic kidney disease stage 5 Retrieved from Nephrology Dialysis and Transplant 22(7) httpswwwncbinlmnihgovpubmed17412702
bull National Kidney Foundation (2002) KDOQI clinical practice guidelines for chronic kidney disease evaluation classification andstratification American Journal of Kidney Disease S1-S266
bull National Kidney Foundation (2014 November 5) Fact Sheets Retrieved from httpwwwkidneyorgnewsnewsroomfactsheetsFastFacts
bull Pal S (2012 June 2) Trends in chronic kidney disease Retrieved from US Pharmacist (37)6 httpswwwuspharmacistcomarticletrends-in-chronic-kidney-disease
bull Qunibi W amp Henrich W L (2017 Jan 19) Overview of chronic kidney disease-mineral and bone disorder (J Berns amp A M Sheridan Eds) Retrieved from UpToDate httpswww-uptodate-comoverview-of-chronic-kidney-disease-mineral-and-bone-disorder-ckd-mbd
bull Rosenberg M (2016 Feb 24) Overview of the management of chronic kidney disease in adults (G C Curhan amp A M Sheridan Eds) Retrieved from UpToDate UpToDate httpswww-uptodate-comproxywichitaeducontentsoverview-of-the-management-of-chronic-kidney-disease-in-adults
BIBLIOGRAPHY
bull Szczech L Stewart R C Hsu-Lin S DeLosky R J Astor B C Fox C H Vassalotti J A (2014) Primary care detection of chronic kidney disease in adults with type 2 diabetes The ADD-CKD Study (Awareness Detection and Drug Therapy in type 2 diabetes and chronic kidney disease PLOS doihttpsdoiorg101371journalpone0110535
bull USRDS (2016) Annual data report 2016 Epidemiology of kidney disease in the United States Retrieved from United States Renal Data System httpswwwusrdsorgadraspx
bull Vasudev B amp Vasudev M (2012) A model curriculum for residents rotating in nephrology MedEDPORTAL doihttpdoiorg1015766mep_2374-82658288
bull Wei L MacDonald T M Jennings C Sheng X amp Flynn R W (2013) Estimated GFR reporting is associated with decreased nonsteroidal anti-inflammatory drug prescribing and increased renal function Kidney International (84)1 174-178
chronic kidney disease in primary care
CKD as a Public Health Issue
Slide Number 3
Costs of CKD in 2013 dollarsUSRDS report
Steps to CKD Patient Care
Renal anatomy and physiology
Definition of Chronic Kidney Disease
CKD Risk Factors
Gaps in CKD Diagnosis
Slide Number 10
Steps to CKD Patient Care
creatinine
Glomerular filtration rate
Slide Number 14
Slide Number 15
Use These Equations Cautiously if at all in hellip
lab albumin creatinine ratio
The New CKD Categories
Steps to CKD Patient Care
Slide Number 20
Kidney Involvement in Systemic Diseases
Slide Number 22
Slide Number 23
DysmorphicRenal Hematuria
Slide Number 25
If you have albuminuria or hematuria-order the following labs
Prevalence of Abnormalities of Mineral Metabolism PTH in CKD
Managing CKD-MBD complications
CKD-MBD Testing
Anemia Becomes More Common as Kidney Function Declines
Detect and Manage CKD Complications
Complications-metabolic acidosis
Complications-vascular calcification
Hyperkalemia management
Hyperuricemia levels amp CKD
CKD monitoring levels 345
Slide Number 59
When to Refer to a Nephrologist
When to Refer
Steps to CKD Patient Care
Kidney transplantation
Starting Dialysis in the ElderlyhellipOr Not
Ckd management
Case 1
Slide Number 67
Lab results
Slide Number 69
Hypertensive nephropathy with proteinuria
Slide Number 71
Case 2
Slide Number 73
Management of CKD in Diabetes
Case 3
Case 3
Systemic Lupus Erythematosus (SLE)
SLE ndash Lupus Nephritis
Case 5
Case 5
Slide Number 81
Slide Number 82
Case study
Slide Number 84
CXR ndash Hilar Lymphadenopathy
Whats needed next
Slide Number 87
newly dx ckd
Slide Number 89
Bibliography
bibliography
bibliography
bibliography
bibliography
Stage 12
Stage 3
Stage 4
Stage 5
Hb le10 gdL
52
56
11
272
Hb gt10-le12 gdL
216
359
426
483
Hb le12 gdL
267
416
536
755
Stage 12
Stage 3
Stage 4
Stage 5
STEPS TO CKD PATIENT CARE
1 CKD definition and risks2 Assess GFR albuminuria3 Determine etiology4 Assess for evidence of progression5 Assess for associated complications6 Discuss dialysistransplantation
CKD-CVD-DIABETES LINK CKD IS A DISEASE MULTIPLIER
National kidney foundation 2014
KDIGO 2017
CKD-MINERAL BONE DISORDERS
bull As kidneys fail they
bull Stop activating calcitriol (the active form of Vit D)mdashcausing calcium imbalance
bull Do not remove phosphorus from bloodmdashleading to phosphorus retention
bull The extra phosphorus pulls calcium out of bones causing them to weaken
bull High phosphorus stimulates PTH release
bull These changes (plus others) cause the start of secondary hyperparathyroidism
bull Labs
bull eGFR
bull Calcium
bull Phos
bull Vit D
bull iPTH
(Qunibi amp Henrich 2017)
PREVALENCE OF ABNORMALITIES OF MINERAL METABOLISM PTH IN CKD
bull Progression of disease ndash declining eGFR increasing proteinuria
bull Degree of proteinuria nephrotic syndrome gt 05-10 gd on ACEi or ARB therapy
bull Etiology of CKD not certain
bull Need help with disease management
bull Indications for kidney biopsy
Rosenberg 2016
WHEN TO REFER
STEPS TO CKD PATIENT CARE
1 CKD definition and risks2 Assess GFR albuminuria3 Determine etiology4 Assess for evidence of progression5 Assess for associated complications6 Discuss dialysistransplantation
KIDNEY TRANSPLANTATION
bull Treatment of choice for ESRDbull Improves quality of lifebull Waiting list time varies-3-5 yearsbull 3 year survival rate after transplantation is 83-94bull Increased risk of cancer
STARTING DIALYSIS IN THE ELDERLYhellipOR NOT
bull Among patients gt 75 yrs with stage 5 CKD who chose to NOT start dialysisbull Overall more likely to die over next 1-2 years bull But if they had ischemic heart disease or other significant comorbidity NO
DIFFERENCE in survival
bull Active disease management and supportive care may be appropriate without starting dialysis in the ill elderly
bull Palliative care does not mean ldquono carerdquo
bull Must have end-of-life discussions
(Murtagh et al 2007)
CKD MANAGEMENTbull Diagnose cause and treat underlying conditionbull Stage per guidelinesbull Slow progression of kidney disease (ACE inhibitors)bull Monitor for complicationsmdashvolume overload hyperkalemia metabolic acidosis
hyperphosphatemia anorexia fatigue htn bone diseasebull Labs cmp cbc phos Vit D 25OH iPTH urine microscopy uric acid urine
proteincr ratio-frequency based off heat map Get sono at least oncebull Vaccinate influenza hep B pneumococcalbull Eval ASCVD risk-likely needs statinbull Possible dexa (donrsquot give bisphosphonates if GFRlt35 let specialist manage)bull Refer to nephrology when eGFR is lt30 (sometimes if higher risk-refer earlier)
CASE 1
bull 55 year old man with past medical history of headaches presents to your office for his first time visit to a PCP in over 30 years
bull He has no past history of being admitted to the hospital and he does not take any OTC medsNSAIDsherbal meds He has no history of ETOH abuse smoking or drug use
bull Vitals BP 180100 mmHg pulse 80 R 18
bull Exam No JVD S1S2 regular PMI shifted to the left no gallop no abdominal bruit pulses bilaterally equal and regular no leg edema
bull What would you order
bull EKG cbc cmp ua urine proteincr ratio lipid
LAB RESULTS
bull Labs reveal a creatinine of 22 mgdL eGFR 33 Urine shows no blood or casts Urineprotein ratio shows 1 gm protein24 hrs EKG shows LVH
bull Next step in workupbull Renal ultrasound 1st then SPEP UPEP with immunofixation serum free light chains
bull Additional labs neg Renal ultrasound shows that both kidneys are slightly reduced in size and are mildly echogenic with no mass or hydronephrosis
bull What is your diagnosis
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileMain_complications_of_persistent_high_blood_pressurepngCreative Commons License associated httpcreativecommonsorglicensesby-sa30
bull 3 months Howevermdashwe have evidence of structural abnormalities Could potentially stage at G3b A3 (red on the heat map)
bull Goal blood pressure
bull JNC 8 14090 NKF 13080
bull Additional lab needed for progression monitoring
bull Cbc renal panel phos Vit D iPTH uric acid urine micro (we already have the renal sono and urine proteincr ratio and lipid)
Selective renal angiography (left lower renal artery) after successful percutaneous balloon dilatation of the stenotic lesionFibromuscular dysplasia in an accessory renal artery causing renovascular hypertension
Secondary Hypertension
Images retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileRenal_FMD2jpg and httpcommonswikimediaorgwikiFileRenal_FMDjpgCreative Commons License associated httpcreativecommonsorglicensesby20deeden (both images)
CASE 2bull OS is a 64year old Hispanic female in for DM check She has had DM for 15+ years and is currently
taking metformin 1000mg bid Lisinopril 10mg a day atorvastatin 40mg a day Labs today showed the following
bull Hgba1c 86 cmp eGFR 50 lipid WNL proteincr ratio 650mg These results are similar to her last visit
bull Upon further hx-you find that she had a recent eye exam and has mild nonproliferaive retinopathy She does not have neuropathy or other ss
bull What further workup do you need
bull Renal sonogram urine micro iPTH vit D (25 OH) phos uric acid
bull Dx stage
bull G3a A3
bull What further treatment do you need
bull Improve glycemic control Increase Lisinopril to 20mg with a goal of 40mg Avoid NSAIDs or other nephrotoxic agents make sure meds are renally dosed monitor 3xyear nephro referral
MANAGEMENT OF CKD IN DIABETESeGFR Recommended
All patients
Yearly measurement of creatinine urinary albumin excretion potassium
45-60 Referral to a nephrologist if possibility for nondiabetickidney disease existsConsider dose adjustment of medicationsMonitor eGFR every 6 monthsMonitor electrolytes bicarbonate hemoglobin calcium phosphorus parathyroid hormone at least yearly
Assure vitamin D sufficiencyConsider bone density testingReferral for dietary counselling
American Diabetes Association Standards of Medical Care in Diabetes Microvascular complications and foot care Diabetes Care 2017 40 (Suppl 1) S88-S98
CASE 3
bull 19 year old African American woman presents to your clinic with complaints of fatigue joint pains a new rash on her face oral ulcer
bull On exam BP 15080 P 88 Afebrile 96 O2 sats on RAbull GEN No respiratory distress at restbull HEENT painless oral ulcer flat rash over malar eminences sparing the nasolabial fold pallor +bull Lungs CTAbull CVS S1S2 regularbull Abdomen soft NTbull Ext left elbow joint and bilateral wrist joints are swollen and tender
bull What would you orderbull CBC CMP ua urine microscopy (microalbumin or urine proteincr ratio) ANA esr RF anti-ccp uric acid TSH
CASE 3
bull Working dx fatigue oral ulcer joint pain
bull Basic Labs Na 135 K 55 Bicarb 18 BUN 50 Cr 35 eGFR 22 Ca 90 ANA + titer 1640
bull UA 3+ blood 3+ protein RBC casts +
bull Given these results what is the most likely diagnosis
bull What would you do
SYSTEMIC LUPUS ERYTHEMATOSUS (SLE)
bull SLE multisystemic disease Etiology unknown
bull Production of autoantibodies and immune complexes formation
bull There is renal involvement in the great majority of patients with SLE at some time of the evolution 66-90
SLE ndash LUPUS NEPHRITIS
bull Race SLE is more commonsevere in African americans than Caucasiansbull
bull Gender female-to-male ratio of 91
bull Age Most patients develop lupus nephritis early in their disease course SLE is more common among women in the third decade of life and lupus nephritis occurs in patients aged 20-40 years
bull Kidney Biopsy For staging lupus nephritis (Class 1-5)
CASE 5bull A 80 year old man who has not seen a PCP in many years
presents to your clinic for weakness for the past few months On further questioning he tells you that his bones also have been hurting lately and he has developed leg swelling in the past month or so
bull On exam bull BP 16090 P 88 Afebrilebull GEN Thin built manbull HEENT pallor presentbull Lungs clearbull CVS S1S2 regular no rub or gallopbull Abdomen soft NTbull Ext 2 + edema
CASE 5
bull Differentials
bull CHF MI Cancer arthritis
bull Labs
bull CBC CMP urine microscopy urine proteincr ratio ESR TSH EKG BNP pa and lat CXR
bull LABS Urine dipstick negative for protein or blood
bull Basic chem bull Na 136 (135-145) K 51 (35-55) Chloride 108 (96-106) Bicarb 25
Given this presentation and the labs (low anion gap and elevated calcium anemia kidney failure) what will you think of What will you order next
Serum and urine protein electrophoresis
Intratubular refractile casts with surrounding syncytial giant cell reaction with chronic tubulointerstitial nephritis and fibrosis characteristic of myeloma cast nephropathy
Kidney Biopsy
CASE STUDYbull A 35 year old African American woman was seen in the clinic for
chronic cough and dyspnea on exertion She gave history of vague symptoms of fatigue and weight loss of 20 Ibs over the last six months
bull List some differentialsbull TB sarcoid lupus thyroid problems PEbull What would you orderbull PPD cbc cmp UA TSH ANA pa and lat cxr
bull Her labs were significant for mildly elevated calcium level and a creatinine of 20 mgdL eGFR 37
bull She had 750 mg of proteinuriaday
bull PPD neg ANA neg TSH and other labs WNL
bull Assuming this is present more than 3 monthshelliphellipwhat is her ckd stage
bull G3b A3
bull What do we still need
CT scan of chest
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileAnterior_mediastinal_mass_thymomajpgCreative Commons License associated httpcreativecommonsorglicensesby20deeden
CXR ndash HILAR LYMPHADENOPATHY
WHATS NEEDED NEXT
bull Biopsy of hilar lymphadenopathy or renal biopsy
bull DX sarcoidosis
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileSarcoidosis_signs_and_symptomsjpgThis work is in the public domain in the United States because it is a work of the United States Federal Government under the terms of Title 17 Chapter 1 Section 105 of the US Code
NEWLY DX CKD
bull 1) urinalysis microscopy ultrasound proteincr ratio
bull If obstruction-treat
bull No obstruction
bull Hx critical (consider myeloma if high risk)
bull glomerular bleeding or albumin in urine
bull Yes workup for glomerular causes (ANArf hep B C upep spep ANCA complement C3 C4)
bull No sterile pyruria-consider interstitial nephritis
bull High risk renovascular disease Evaluate renovascular disease
Additional Online Resources for CKD LearningbullNational Kidney Foundation wwwkidneyorgbullUnited States Renal Data Service wwwusrdsorgbullCDCrsquos CKD Surveillance Project
httpnccdcdcgovckdbullNational Kidney Disease Education Program
(NKDEP) httpnkdepnihgov
BIBLIOGRAPHY
bull Afzali B amp Goldsmith D J (2016 June 29) Statins and chronic kidney disease (G C Curhan amp A M Sheridan Eds) Retrieved 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsstatins-and-chronic-kidney-disease
bull American Diabetes Association Standards of Medical Care in Diabetes (2017) Microvascular complications and foot care Diabetes Care 2017 (40) S88-S98
bull American Diabetes Association Standards of Medical Care in Diabetes (2017) Microvascular complications and foot care Diabetes Care 40 (suppl 1) S88-S98
bull Berns J S (2017 Mar 22) Treatment of anemia in nondialysis chronic kidney disease (T A Golper amp A M Sheridan Eds) Retrieved from UpToDate httpswww-uptodate-comproxywichitaeducontentstreatment-of-anemia-in-nondialysis-chronic-kidney-disease
bull Chan M Dall A T Fletcher K E Lu N amp Trivedi H (2007) Outcomes in patients with chronic kidney disease referred late to nephrologists a meta-analysis American Journal of Medicine 120(12) 1063-1070
bull Coresh J Selvin E amp Stevens L A (2007) Prevalence of chronic kidny disease in the United States JAMA 298(17) doi101001jama298172038
bull de Brito-Ashurst I Varagunam M Raftery M amp Yagoob M (2009) Bicarbonate supplementation slows progression of CKD and improves nutritional status Journal of American Society of Nephrology (20) 2075-2084
BIBLIOGRAPHY
bull Duncan L Heathcoat J Djurdjev O amp Levin A (2001) Screening for renal disease using serum creatinine who are we missing Nephrology Dialysis and Transplant 16(5) 1042-1046
bull Dunkler D Gao P Lee S F Heinz G Clase C M Tobe S Oberbauer R (2015 August 7) Risk prediction for early CKD in type 2 diabetes Retrieved from Clinical Journal of the American Society of Nephrology httpcjasnasnjournalsorgcontent1081371fullsid=61422554-a5f1-41ac-b696-dcd3b12bd268
bull Fatehi P amp Chi-yuan H (September 15 2016) Diagnostic approach to the patient with newly identified chronic kidney disease (G C Curhan amp A M Sheridan Eds) Retrieved May 7 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsdiagnostic-approach-to-the-patient-with-newly-identified-chronic-kidney-disease
bull Fink J e (2009) Chronic Kidney Disease as an Under-Recognized Threat to Patient Safety American journal of kidney diseases the official journal of the National Kidney Foundation 53(4) 681-688
bull Gaffo A L amp Saag K G (2008 Nov) Management of hyperuricemia and gout in CKD doihttpdxdoiorg101053jajkd200807035
bull Hebert L A amp Parikh S V (2014 June 18) Differential diagnosis and evaluation of glomerular disease (R J Glassock amp A Q Lam Eds) Retrieved May 7 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsdifferential-diagnosis-and-evaluation-of-glomerular-disease
bull Inker L Perrone R D Sterns R H amp Forman J P (2017 March 7) Assessment of kidney function Retrieved from UpToDate httpswww-uptodate-comproxywichitaeducontentsassessment-of-kidney-functionsource=search_resultampsearch=creatinineampselectedTitle=1~150
BIBLIOGRAPHY
bull James P A Ortiz E amp Et Al (2014) Evidence based guideline for the management of high blood pressure in adults (JNC) JAMA 311(5) 507-520
bull Kidney Disease Improving Global Outcomes (KDIGO) CKD Work Group (2013 January) KDIGO 2012 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease Retrieved from Kidney International Supplement httpwwwkidney-internationalorg
bull Kunz R Friedrich C Wolbers M amp Mann J F (2008) Meta-analysis effect of monotherapy and combination therapy with inhibitors of the renin angiotensin system on proteinuria in renal disease Annals of Internal Medicine 148(1) 30-48
bull Levey A Stevens L A Schmid C H Castro A F Feldman H I Kusek J W Coresh J (2009) A new equation to estimate glomerular filtration rate Annals of Internal Medicine 150(9) 604-612
bull Levin A Bakris G L Molitch M Smulders M M Williams L A amp Andress D L (2007 Jan) Prevalence of abnormal serum vitamin D PTH calcium and phosphorus in patients with chronic kidney disease results of the study to evaluate early kidney disease Kidney International 71(1) 31-38 Retrieved from PubMED
bull Mahajan A Simoni J Sheather S Broglio K Rajab M amp Wesson D (2010) Daily oral sodium bicarbonate preserves glomerular filtration rate by slowing its decline in early hypertensive nephropathy Kidney International (78_ 303-309
bull Mann J Schmieder R E amp McQueen M (2008) Renal outcomes with telmisartan ramipril or both in people at high vascular risk (the ONTARGET study) a multicentre randomised doubleblind ocntrolled trial Lancet 372(9638) 547-533
BIBLIOGRAPHY
bull Matovinović M S (2009) Pathophysiology and classification of kidney disease Retrieved from The Journal of the International Federation of Clinical Chemistry and Laboratory Medicine httpwwwifccorgifccfilesdocs20010902pdf
bull Moe S Drueke T Lameire N amp Eknoyan G (2007 Jan) Chronic kidney disease-mineral-bone disorder a new paradigmdoi101053jackd200610005
bull Murtagh F E Marsh J E Donohoe P Ekbal N J Sheerin N S amp Harris F E (2007 July) Dialysis or not A comparative survival study of patients over 75 years with chronic kidney disease stage 5 Retrieved from Nephrology Dialysis and Transplant 22(7) httpswwwncbinlmnihgovpubmed17412702
bull National Kidney Foundation (2002) KDOQI clinical practice guidelines for chronic kidney disease evaluation classification andstratification American Journal of Kidney Disease S1-S266
bull National Kidney Foundation (2014 November 5) Fact Sheets Retrieved from httpwwwkidneyorgnewsnewsroomfactsheetsFastFacts
bull Pal S (2012 June 2) Trends in chronic kidney disease Retrieved from US Pharmacist (37)6 httpswwwuspharmacistcomarticletrends-in-chronic-kidney-disease
bull Qunibi W amp Henrich W L (2017 Jan 19) Overview of chronic kidney disease-mineral and bone disorder (J Berns amp A M Sheridan Eds) Retrieved from UpToDate httpswww-uptodate-comoverview-of-chronic-kidney-disease-mineral-and-bone-disorder-ckd-mbd
bull Rosenberg M (2016 Feb 24) Overview of the management of chronic kidney disease in adults (G C Curhan amp A M Sheridan Eds) Retrieved from UpToDate UpToDate httpswww-uptodate-comproxywichitaeducontentsoverview-of-the-management-of-chronic-kidney-disease-in-adults
BIBLIOGRAPHY
bull Szczech L Stewart R C Hsu-Lin S DeLosky R J Astor B C Fox C H Vassalotti J A (2014) Primary care detection of chronic kidney disease in adults with type 2 diabetes The ADD-CKD Study (Awareness Detection and Drug Therapy in type 2 diabetes and chronic kidney disease PLOS doihttpsdoiorg101371journalpone0110535
bull USRDS (2016) Annual data report 2016 Epidemiology of kidney disease in the United States Retrieved from United States Renal Data System httpswwwusrdsorgadraspx
bull Vasudev B amp Vasudev M (2012) A model curriculum for residents rotating in nephrology MedEDPORTAL doihttpdoiorg1015766mep_2374-82658288
bull Wei L MacDonald T M Jennings C Sheng X amp Flynn R W (2013) Estimated GFR reporting is associated with decreased nonsteroidal anti-inflammatory drug prescribing and increased renal function Kidney International (84)1 174-178
chronic kidney disease in primary care
CKD as a Public Health Issue
Slide Number 3
Costs of CKD in 2013 dollarsUSRDS report
Steps to CKD Patient Care
Renal anatomy and physiology
Definition of Chronic Kidney Disease
CKD Risk Factors
Gaps in CKD Diagnosis
Slide Number 10
Steps to CKD Patient Care
creatinine
Glomerular filtration rate
Slide Number 14
Slide Number 15
Use These Equations Cautiously if at all in hellip
lab albumin creatinine ratio
The New CKD Categories
Steps to CKD Patient Care
Slide Number 20
Kidney Involvement in Systemic Diseases
Slide Number 22
Slide Number 23
DysmorphicRenal Hematuria
Slide Number 25
If you have albuminuria or hematuria-order the following labs
bull Progression of disease ndash declining eGFR increasing proteinuria
bull Degree of proteinuria nephrotic syndrome gt 05-10 gd on ACEi or ARB therapy
bull Etiology of CKD not certain
bull Need help with disease management
bull Indications for kidney biopsy
Rosenberg 2016
WHEN TO REFER
STEPS TO CKD PATIENT CARE
1 CKD definition and risks2 Assess GFR albuminuria3 Determine etiology4 Assess for evidence of progression5 Assess for associated complications6 Discuss dialysistransplantation
KIDNEY TRANSPLANTATION
bull Treatment of choice for ESRDbull Improves quality of lifebull Waiting list time varies-3-5 yearsbull 3 year survival rate after transplantation is 83-94bull Increased risk of cancer
STARTING DIALYSIS IN THE ELDERLYhellipOR NOT
bull Among patients gt 75 yrs with stage 5 CKD who chose to NOT start dialysisbull Overall more likely to die over next 1-2 years bull But if they had ischemic heart disease or other significant comorbidity NO
DIFFERENCE in survival
bull Active disease management and supportive care may be appropriate without starting dialysis in the ill elderly
bull Palliative care does not mean ldquono carerdquo
bull Must have end-of-life discussions
(Murtagh et al 2007)
CKD MANAGEMENTbull Diagnose cause and treat underlying conditionbull Stage per guidelinesbull Slow progression of kidney disease (ACE inhibitors)bull Monitor for complicationsmdashvolume overload hyperkalemia metabolic acidosis
hyperphosphatemia anorexia fatigue htn bone diseasebull Labs cmp cbc phos Vit D 25OH iPTH urine microscopy uric acid urine
proteincr ratio-frequency based off heat map Get sono at least oncebull Vaccinate influenza hep B pneumococcalbull Eval ASCVD risk-likely needs statinbull Possible dexa (donrsquot give bisphosphonates if GFRlt35 let specialist manage)bull Refer to nephrology when eGFR is lt30 (sometimes if higher risk-refer earlier)
CASE 1
bull 55 year old man with past medical history of headaches presents to your office for his first time visit to a PCP in over 30 years
bull He has no past history of being admitted to the hospital and he does not take any OTC medsNSAIDsherbal meds He has no history of ETOH abuse smoking or drug use
bull Vitals BP 180100 mmHg pulse 80 R 18
bull Exam No JVD S1S2 regular PMI shifted to the left no gallop no abdominal bruit pulses bilaterally equal and regular no leg edema
bull What would you order
bull EKG cbc cmp ua urine proteincr ratio lipid
LAB RESULTS
bull Labs reveal a creatinine of 22 mgdL eGFR 33 Urine shows no blood or casts Urineprotein ratio shows 1 gm protein24 hrs EKG shows LVH
bull Next step in workupbull Renal ultrasound 1st then SPEP UPEP with immunofixation serum free light chains
bull Additional labs neg Renal ultrasound shows that both kidneys are slightly reduced in size and are mildly echogenic with no mass or hydronephrosis
bull What is your diagnosis
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileMain_complications_of_persistent_high_blood_pressurepngCreative Commons License associated httpcreativecommonsorglicensesby-sa30
bull 3 months Howevermdashwe have evidence of structural abnormalities Could potentially stage at G3b A3 (red on the heat map)
bull Goal blood pressure
bull JNC 8 14090 NKF 13080
bull Additional lab needed for progression monitoring
bull Cbc renal panel phos Vit D iPTH uric acid urine micro (we already have the renal sono and urine proteincr ratio and lipid)
Selective renal angiography (left lower renal artery) after successful percutaneous balloon dilatation of the stenotic lesionFibromuscular dysplasia in an accessory renal artery causing renovascular hypertension
Secondary Hypertension
Images retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileRenal_FMD2jpg and httpcommonswikimediaorgwikiFileRenal_FMDjpgCreative Commons License associated httpcreativecommonsorglicensesby20deeden (both images)
CASE 2bull OS is a 64year old Hispanic female in for DM check She has had DM for 15+ years and is currently
taking metformin 1000mg bid Lisinopril 10mg a day atorvastatin 40mg a day Labs today showed the following
bull Hgba1c 86 cmp eGFR 50 lipid WNL proteincr ratio 650mg These results are similar to her last visit
bull Upon further hx-you find that she had a recent eye exam and has mild nonproliferaive retinopathy She does not have neuropathy or other ss
bull What further workup do you need
bull Renal sonogram urine micro iPTH vit D (25 OH) phos uric acid
bull Dx stage
bull G3a A3
bull What further treatment do you need
bull Improve glycemic control Increase Lisinopril to 20mg with a goal of 40mg Avoid NSAIDs or other nephrotoxic agents make sure meds are renally dosed monitor 3xyear nephro referral
MANAGEMENT OF CKD IN DIABETESeGFR Recommended
All patients
Yearly measurement of creatinine urinary albumin excretion potassium
45-60 Referral to a nephrologist if possibility for nondiabetickidney disease existsConsider dose adjustment of medicationsMonitor eGFR every 6 monthsMonitor electrolytes bicarbonate hemoglobin calcium phosphorus parathyroid hormone at least yearly
Assure vitamin D sufficiencyConsider bone density testingReferral for dietary counselling
American Diabetes Association Standards of Medical Care in Diabetes Microvascular complications and foot care Diabetes Care 2017 40 (Suppl 1) S88-S98
CASE 3
bull 19 year old African American woman presents to your clinic with complaints of fatigue joint pains a new rash on her face oral ulcer
bull On exam BP 15080 P 88 Afebrile 96 O2 sats on RAbull GEN No respiratory distress at restbull HEENT painless oral ulcer flat rash over malar eminences sparing the nasolabial fold pallor +bull Lungs CTAbull CVS S1S2 regularbull Abdomen soft NTbull Ext left elbow joint and bilateral wrist joints are swollen and tender
bull What would you orderbull CBC CMP ua urine microscopy (microalbumin or urine proteincr ratio) ANA esr RF anti-ccp uric acid TSH
CASE 3
bull Working dx fatigue oral ulcer joint pain
bull Basic Labs Na 135 K 55 Bicarb 18 BUN 50 Cr 35 eGFR 22 Ca 90 ANA + titer 1640
bull UA 3+ blood 3+ protein RBC casts +
bull Given these results what is the most likely diagnosis
bull What would you do
SYSTEMIC LUPUS ERYTHEMATOSUS (SLE)
bull SLE multisystemic disease Etiology unknown
bull Production of autoantibodies and immune complexes formation
bull There is renal involvement in the great majority of patients with SLE at some time of the evolution 66-90
SLE ndash LUPUS NEPHRITIS
bull Race SLE is more commonsevere in African americans than Caucasiansbull
bull Gender female-to-male ratio of 91
bull Age Most patients develop lupus nephritis early in their disease course SLE is more common among women in the third decade of life and lupus nephritis occurs in patients aged 20-40 years
bull Kidney Biopsy For staging lupus nephritis (Class 1-5)
CASE 5bull A 80 year old man who has not seen a PCP in many years
presents to your clinic for weakness for the past few months On further questioning he tells you that his bones also have been hurting lately and he has developed leg swelling in the past month or so
bull On exam bull BP 16090 P 88 Afebrilebull GEN Thin built manbull HEENT pallor presentbull Lungs clearbull CVS S1S2 regular no rub or gallopbull Abdomen soft NTbull Ext 2 + edema
CASE 5
bull Differentials
bull CHF MI Cancer arthritis
bull Labs
bull CBC CMP urine microscopy urine proteincr ratio ESR TSH EKG BNP pa and lat CXR
bull LABS Urine dipstick negative for protein or blood
bull Basic chem bull Na 136 (135-145) K 51 (35-55) Chloride 108 (96-106) Bicarb 25
Given this presentation and the labs (low anion gap and elevated calcium anemia kidney failure) what will you think of What will you order next
Serum and urine protein electrophoresis
Intratubular refractile casts with surrounding syncytial giant cell reaction with chronic tubulointerstitial nephritis and fibrosis characteristic of myeloma cast nephropathy
Kidney Biopsy
CASE STUDYbull A 35 year old African American woman was seen in the clinic for
chronic cough and dyspnea on exertion She gave history of vague symptoms of fatigue and weight loss of 20 Ibs over the last six months
bull List some differentialsbull TB sarcoid lupus thyroid problems PEbull What would you orderbull PPD cbc cmp UA TSH ANA pa and lat cxr
bull Her labs were significant for mildly elevated calcium level and a creatinine of 20 mgdL eGFR 37
bull She had 750 mg of proteinuriaday
bull PPD neg ANA neg TSH and other labs WNL
bull Assuming this is present more than 3 monthshelliphellipwhat is her ckd stage
bull G3b A3
bull What do we still need
CT scan of chest
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileAnterior_mediastinal_mass_thymomajpgCreative Commons License associated httpcreativecommonsorglicensesby20deeden
CXR ndash HILAR LYMPHADENOPATHY
WHATS NEEDED NEXT
bull Biopsy of hilar lymphadenopathy or renal biopsy
bull DX sarcoidosis
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileSarcoidosis_signs_and_symptomsjpgThis work is in the public domain in the United States because it is a work of the United States Federal Government under the terms of Title 17 Chapter 1 Section 105 of the US Code
NEWLY DX CKD
bull 1) urinalysis microscopy ultrasound proteincr ratio
bull If obstruction-treat
bull No obstruction
bull Hx critical (consider myeloma if high risk)
bull glomerular bleeding or albumin in urine
bull Yes workup for glomerular causes (ANArf hep B C upep spep ANCA complement C3 C4)
bull No sterile pyruria-consider interstitial nephritis
bull High risk renovascular disease Evaluate renovascular disease
Additional Online Resources for CKD LearningbullNational Kidney Foundation wwwkidneyorgbullUnited States Renal Data Service wwwusrdsorgbullCDCrsquos CKD Surveillance Project
httpnccdcdcgovckdbullNational Kidney Disease Education Program
(NKDEP) httpnkdepnihgov
BIBLIOGRAPHY
bull Afzali B amp Goldsmith D J (2016 June 29) Statins and chronic kidney disease (G C Curhan amp A M Sheridan Eds) Retrieved 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsstatins-and-chronic-kidney-disease
bull American Diabetes Association Standards of Medical Care in Diabetes (2017) Microvascular complications and foot care Diabetes Care 2017 (40) S88-S98
bull American Diabetes Association Standards of Medical Care in Diabetes (2017) Microvascular complications and foot care Diabetes Care 40 (suppl 1) S88-S98
bull Berns J S (2017 Mar 22) Treatment of anemia in nondialysis chronic kidney disease (T A Golper amp A M Sheridan Eds) Retrieved from UpToDate httpswww-uptodate-comproxywichitaeducontentstreatment-of-anemia-in-nondialysis-chronic-kidney-disease
bull Chan M Dall A T Fletcher K E Lu N amp Trivedi H (2007) Outcomes in patients with chronic kidney disease referred late to nephrologists a meta-analysis American Journal of Medicine 120(12) 1063-1070
bull Coresh J Selvin E amp Stevens L A (2007) Prevalence of chronic kidny disease in the United States JAMA 298(17) doi101001jama298172038
bull de Brito-Ashurst I Varagunam M Raftery M amp Yagoob M (2009) Bicarbonate supplementation slows progression of CKD and improves nutritional status Journal of American Society of Nephrology (20) 2075-2084
BIBLIOGRAPHY
bull Duncan L Heathcoat J Djurdjev O amp Levin A (2001) Screening for renal disease using serum creatinine who are we missing Nephrology Dialysis and Transplant 16(5) 1042-1046
bull Dunkler D Gao P Lee S F Heinz G Clase C M Tobe S Oberbauer R (2015 August 7) Risk prediction for early CKD in type 2 diabetes Retrieved from Clinical Journal of the American Society of Nephrology httpcjasnasnjournalsorgcontent1081371fullsid=61422554-a5f1-41ac-b696-dcd3b12bd268
bull Fatehi P amp Chi-yuan H (September 15 2016) Diagnostic approach to the patient with newly identified chronic kidney disease (G C Curhan amp A M Sheridan Eds) Retrieved May 7 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsdiagnostic-approach-to-the-patient-with-newly-identified-chronic-kidney-disease
bull Fink J e (2009) Chronic Kidney Disease as an Under-Recognized Threat to Patient Safety American journal of kidney diseases the official journal of the National Kidney Foundation 53(4) 681-688
bull Gaffo A L amp Saag K G (2008 Nov) Management of hyperuricemia and gout in CKD doihttpdxdoiorg101053jajkd200807035
bull Hebert L A amp Parikh S V (2014 June 18) Differential diagnosis and evaluation of glomerular disease (R J Glassock amp A Q Lam Eds) Retrieved May 7 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsdifferential-diagnosis-and-evaluation-of-glomerular-disease
bull Inker L Perrone R D Sterns R H amp Forman J P (2017 March 7) Assessment of kidney function Retrieved from UpToDate httpswww-uptodate-comproxywichitaeducontentsassessment-of-kidney-functionsource=search_resultampsearch=creatinineampselectedTitle=1~150
BIBLIOGRAPHY
bull James P A Ortiz E amp Et Al (2014) Evidence based guideline for the management of high blood pressure in adults (JNC) JAMA 311(5) 507-520
bull Kidney Disease Improving Global Outcomes (KDIGO) CKD Work Group (2013 January) KDIGO 2012 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease Retrieved from Kidney International Supplement httpwwwkidney-internationalorg
bull Kunz R Friedrich C Wolbers M amp Mann J F (2008) Meta-analysis effect of monotherapy and combination therapy with inhibitors of the renin angiotensin system on proteinuria in renal disease Annals of Internal Medicine 148(1) 30-48
bull Levey A Stevens L A Schmid C H Castro A F Feldman H I Kusek J W Coresh J (2009) A new equation to estimate glomerular filtration rate Annals of Internal Medicine 150(9) 604-612
bull Levin A Bakris G L Molitch M Smulders M M Williams L A amp Andress D L (2007 Jan) Prevalence of abnormal serum vitamin D PTH calcium and phosphorus in patients with chronic kidney disease results of the study to evaluate early kidney disease Kidney International 71(1) 31-38 Retrieved from PubMED
bull Mahajan A Simoni J Sheather S Broglio K Rajab M amp Wesson D (2010) Daily oral sodium bicarbonate preserves glomerular filtration rate by slowing its decline in early hypertensive nephropathy Kidney International (78_ 303-309
bull Mann J Schmieder R E amp McQueen M (2008) Renal outcomes with telmisartan ramipril or both in people at high vascular risk (the ONTARGET study) a multicentre randomised doubleblind ocntrolled trial Lancet 372(9638) 547-533
BIBLIOGRAPHY
bull Matovinović M S (2009) Pathophysiology and classification of kidney disease Retrieved from The Journal of the International Federation of Clinical Chemistry and Laboratory Medicine httpwwwifccorgifccfilesdocs20010902pdf
bull Moe S Drueke T Lameire N amp Eknoyan G (2007 Jan) Chronic kidney disease-mineral-bone disorder a new paradigmdoi101053jackd200610005
bull Murtagh F E Marsh J E Donohoe P Ekbal N J Sheerin N S amp Harris F E (2007 July) Dialysis or not A comparative survival study of patients over 75 years with chronic kidney disease stage 5 Retrieved from Nephrology Dialysis and Transplant 22(7) httpswwwncbinlmnihgovpubmed17412702
bull National Kidney Foundation (2002) KDOQI clinical practice guidelines for chronic kidney disease evaluation classification andstratification American Journal of Kidney Disease S1-S266
bull National Kidney Foundation (2014 November 5) Fact Sheets Retrieved from httpwwwkidneyorgnewsnewsroomfactsheetsFastFacts
bull Pal S (2012 June 2) Trends in chronic kidney disease Retrieved from US Pharmacist (37)6 httpswwwuspharmacistcomarticletrends-in-chronic-kidney-disease
bull Qunibi W amp Henrich W L (2017 Jan 19) Overview of chronic kidney disease-mineral and bone disorder (J Berns amp A M Sheridan Eds) Retrieved from UpToDate httpswww-uptodate-comoverview-of-chronic-kidney-disease-mineral-and-bone-disorder-ckd-mbd
bull Rosenberg M (2016 Feb 24) Overview of the management of chronic kidney disease in adults (G C Curhan amp A M Sheridan Eds) Retrieved from UpToDate UpToDate httpswww-uptodate-comproxywichitaeducontentsoverview-of-the-management-of-chronic-kidney-disease-in-adults
BIBLIOGRAPHY
bull Szczech L Stewart R C Hsu-Lin S DeLosky R J Astor B C Fox C H Vassalotti J A (2014) Primary care detection of chronic kidney disease in adults with type 2 diabetes The ADD-CKD Study (Awareness Detection and Drug Therapy in type 2 diabetes and chronic kidney disease PLOS doihttpsdoiorg101371journalpone0110535
bull USRDS (2016) Annual data report 2016 Epidemiology of kidney disease in the United States Retrieved from United States Renal Data System httpswwwusrdsorgadraspx
bull Vasudev B amp Vasudev M (2012) A model curriculum for residents rotating in nephrology MedEDPORTAL doihttpdoiorg1015766mep_2374-82658288
bull Wei L MacDonald T M Jennings C Sheng X amp Flynn R W (2013) Estimated GFR reporting is associated with decreased nonsteroidal anti-inflammatory drug prescribing and increased renal function Kidney International (84)1 174-178
chronic kidney disease in primary care
CKD as a Public Health Issue
Slide Number 3
Costs of CKD in 2013 dollarsUSRDS report
Steps to CKD Patient Care
Renal anatomy and physiology
Definition of Chronic Kidney Disease
CKD Risk Factors
Gaps in CKD Diagnosis
Slide Number 10
Steps to CKD Patient Care
creatinine
Glomerular filtration rate
Slide Number 14
Slide Number 15
Use These Equations Cautiously if at all in hellip
lab albumin creatinine ratio
The New CKD Categories
Steps to CKD Patient Care
Slide Number 20
Kidney Involvement in Systemic Diseases
Slide Number 22
Slide Number 23
DysmorphicRenal Hematuria
Slide Number 25
If you have albuminuria or hematuria-order the following labs
bull Progression of disease ndash declining eGFR increasing proteinuria
bull Degree of proteinuria nephrotic syndrome gt 05-10 gd on ACEi or ARB therapy
bull Etiology of CKD not certain
bull Need help with disease management
bull Indications for kidney biopsy
Rosenberg 2016
WHEN TO REFER
STEPS TO CKD PATIENT CARE
1 CKD definition and risks2 Assess GFR albuminuria3 Determine etiology4 Assess for evidence of progression5 Assess for associated complications6 Discuss dialysistransplantation
KIDNEY TRANSPLANTATION
bull Treatment of choice for ESRDbull Improves quality of lifebull Waiting list time varies-3-5 yearsbull 3 year survival rate after transplantation is 83-94bull Increased risk of cancer
STARTING DIALYSIS IN THE ELDERLYhellipOR NOT
bull Among patients gt 75 yrs with stage 5 CKD who chose to NOT start dialysisbull Overall more likely to die over next 1-2 years bull But if they had ischemic heart disease or other significant comorbidity NO
DIFFERENCE in survival
bull Active disease management and supportive care may be appropriate without starting dialysis in the ill elderly
bull Palliative care does not mean ldquono carerdquo
bull Must have end-of-life discussions
(Murtagh et al 2007)
CKD MANAGEMENTbull Diagnose cause and treat underlying conditionbull Stage per guidelinesbull Slow progression of kidney disease (ACE inhibitors)bull Monitor for complicationsmdashvolume overload hyperkalemia metabolic acidosis
hyperphosphatemia anorexia fatigue htn bone diseasebull Labs cmp cbc phos Vit D 25OH iPTH urine microscopy uric acid urine
proteincr ratio-frequency based off heat map Get sono at least oncebull Vaccinate influenza hep B pneumococcalbull Eval ASCVD risk-likely needs statinbull Possible dexa (donrsquot give bisphosphonates if GFRlt35 let specialist manage)bull Refer to nephrology when eGFR is lt30 (sometimes if higher risk-refer earlier)
CASE 1
bull 55 year old man with past medical history of headaches presents to your office for his first time visit to a PCP in over 30 years
bull He has no past history of being admitted to the hospital and he does not take any OTC medsNSAIDsherbal meds He has no history of ETOH abuse smoking or drug use
bull Vitals BP 180100 mmHg pulse 80 R 18
bull Exam No JVD S1S2 regular PMI shifted to the left no gallop no abdominal bruit pulses bilaterally equal and regular no leg edema
bull What would you order
bull EKG cbc cmp ua urine proteincr ratio lipid
LAB RESULTS
bull Labs reveal a creatinine of 22 mgdL eGFR 33 Urine shows no blood or casts Urineprotein ratio shows 1 gm protein24 hrs EKG shows LVH
bull Next step in workupbull Renal ultrasound 1st then SPEP UPEP with immunofixation serum free light chains
bull Additional labs neg Renal ultrasound shows that both kidneys are slightly reduced in size and are mildly echogenic with no mass or hydronephrosis
bull What is your diagnosis
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileMain_complications_of_persistent_high_blood_pressurepngCreative Commons License associated httpcreativecommonsorglicensesby-sa30
bull 3 months Howevermdashwe have evidence of structural abnormalities Could potentially stage at G3b A3 (red on the heat map)
bull Goal blood pressure
bull JNC 8 14090 NKF 13080
bull Additional lab needed for progression monitoring
bull Cbc renal panel phos Vit D iPTH uric acid urine micro (we already have the renal sono and urine proteincr ratio and lipid)
Selective renal angiography (left lower renal artery) after successful percutaneous balloon dilatation of the stenotic lesionFibromuscular dysplasia in an accessory renal artery causing renovascular hypertension
Secondary Hypertension
Images retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileRenal_FMD2jpg and httpcommonswikimediaorgwikiFileRenal_FMDjpgCreative Commons License associated httpcreativecommonsorglicensesby20deeden (both images)
CASE 2bull OS is a 64year old Hispanic female in for DM check She has had DM for 15+ years and is currently
taking metformin 1000mg bid Lisinopril 10mg a day atorvastatin 40mg a day Labs today showed the following
bull Hgba1c 86 cmp eGFR 50 lipid WNL proteincr ratio 650mg These results are similar to her last visit
bull Upon further hx-you find that she had a recent eye exam and has mild nonproliferaive retinopathy She does not have neuropathy or other ss
bull What further workup do you need
bull Renal sonogram urine micro iPTH vit D (25 OH) phos uric acid
bull Dx stage
bull G3a A3
bull What further treatment do you need
bull Improve glycemic control Increase Lisinopril to 20mg with a goal of 40mg Avoid NSAIDs or other nephrotoxic agents make sure meds are renally dosed monitor 3xyear nephro referral
MANAGEMENT OF CKD IN DIABETESeGFR Recommended
All patients
Yearly measurement of creatinine urinary albumin excretion potassium
45-60 Referral to a nephrologist if possibility for nondiabetickidney disease existsConsider dose adjustment of medicationsMonitor eGFR every 6 monthsMonitor electrolytes bicarbonate hemoglobin calcium phosphorus parathyroid hormone at least yearly
Assure vitamin D sufficiencyConsider bone density testingReferral for dietary counselling
American Diabetes Association Standards of Medical Care in Diabetes Microvascular complications and foot care Diabetes Care 2017 40 (Suppl 1) S88-S98
CASE 3
bull 19 year old African American woman presents to your clinic with complaints of fatigue joint pains a new rash on her face oral ulcer
bull On exam BP 15080 P 88 Afebrile 96 O2 sats on RAbull GEN No respiratory distress at restbull HEENT painless oral ulcer flat rash over malar eminences sparing the nasolabial fold pallor +bull Lungs CTAbull CVS S1S2 regularbull Abdomen soft NTbull Ext left elbow joint and bilateral wrist joints are swollen and tender
bull What would you orderbull CBC CMP ua urine microscopy (microalbumin or urine proteincr ratio) ANA esr RF anti-ccp uric acid TSH
CASE 3
bull Working dx fatigue oral ulcer joint pain
bull Basic Labs Na 135 K 55 Bicarb 18 BUN 50 Cr 35 eGFR 22 Ca 90 ANA + titer 1640
bull UA 3+ blood 3+ protein RBC casts +
bull Given these results what is the most likely diagnosis
bull What would you do
SYSTEMIC LUPUS ERYTHEMATOSUS (SLE)
bull SLE multisystemic disease Etiology unknown
bull Production of autoantibodies and immune complexes formation
bull There is renal involvement in the great majority of patients with SLE at some time of the evolution 66-90
SLE ndash LUPUS NEPHRITIS
bull Race SLE is more commonsevere in African americans than Caucasiansbull
bull Gender female-to-male ratio of 91
bull Age Most patients develop lupus nephritis early in their disease course SLE is more common among women in the third decade of life and lupus nephritis occurs in patients aged 20-40 years
bull Kidney Biopsy For staging lupus nephritis (Class 1-5)
CASE 5bull A 80 year old man who has not seen a PCP in many years
presents to your clinic for weakness for the past few months On further questioning he tells you that his bones also have been hurting lately and he has developed leg swelling in the past month or so
bull On exam bull BP 16090 P 88 Afebrilebull GEN Thin built manbull HEENT pallor presentbull Lungs clearbull CVS S1S2 regular no rub or gallopbull Abdomen soft NTbull Ext 2 + edema
CASE 5
bull Differentials
bull CHF MI Cancer arthritis
bull Labs
bull CBC CMP urine microscopy urine proteincr ratio ESR TSH EKG BNP pa and lat CXR
bull LABS Urine dipstick negative for protein or blood
bull Basic chem bull Na 136 (135-145) K 51 (35-55) Chloride 108 (96-106) Bicarb 25
Given this presentation and the labs (low anion gap and elevated calcium anemia kidney failure) what will you think of What will you order next
Serum and urine protein electrophoresis
Intratubular refractile casts with surrounding syncytial giant cell reaction with chronic tubulointerstitial nephritis and fibrosis characteristic of myeloma cast nephropathy
Kidney Biopsy
CASE STUDYbull A 35 year old African American woman was seen in the clinic for
chronic cough and dyspnea on exertion She gave history of vague symptoms of fatigue and weight loss of 20 Ibs over the last six months
bull List some differentialsbull TB sarcoid lupus thyroid problems PEbull What would you orderbull PPD cbc cmp UA TSH ANA pa and lat cxr
bull Her labs were significant for mildly elevated calcium level and a creatinine of 20 mgdL eGFR 37
bull She had 750 mg of proteinuriaday
bull PPD neg ANA neg TSH and other labs WNL
bull Assuming this is present more than 3 monthshelliphellipwhat is her ckd stage
bull G3b A3
bull What do we still need
CT scan of chest
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileAnterior_mediastinal_mass_thymomajpgCreative Commons License associated httpcreativecommonsorglicensesby20deeden
CXR ndash HILAR LYMPHADENOPATHY
WHATS NEEDED NEXT
bull Biopsy of hilar lymphadenopathy or renal biopsy
bull DX sarcoidosis
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileSarcoidosis_signs_and_symptomsjpgThis work is in the public domain in the United States because it is a work of the United States Federal Government under the terms of Title 17 Chapter 1 Section 105 of the US Code
NEWLY DX CKD
bull 1) urinalysis microscopy ultrasound proteincr ratio
bull If obstruction-treat
bull No obstruction
bull Hx critical (consider myeloma if high risk)
bull glomerular bleeding or albumin in urine
bull Yes workup for glomerular causes (ANArf hep B C upep spep ANCA complement C3 C4)
bull No sterile pyruria-consider interstitial nephritis
bull High risk renovascular disease Evaluate renovascular disease
Additional Online Resources for CKD LearningbullNational Kidney Foundation wwwkidneyorgbullUnited States Renal Data Service wwwusrdsorgbullCDCrsquos CKD Surveillance Project
httpnccdcdcgovckdbullNational Kidney Disease Education Program
(NKDEP) httpnkdepnihgov
BIBLIOGRAPHY
bull Afzali B amp Goldsmith D J (2016 June 29) Statins and chronic kidney disease (G C Curhan amp A M Sheridan Eds) Retrieved 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsstatins-and-chronic-kidney-disease
bull American Diabetes Association Standards of Medical Care in Diabetes (2017) Microvascular complications and foot care Diabetes Care 2017 (40) S88-S98
bull American Diabetes Association Standards of Medical Care in Diabetes (2017) Microvascular complications and foot care Diabetes Care 40 (suppl 1) S88-S98
bull Berns J S (2017 Mar 22) Treatment of anemia in nondialysis chronic kidney disease (T A Golper amp A M Sheridan Eds) Retrieved from UpToDate httpswww-uptodate-comproxywichitaeducontentstreatment-of-anemia-in-nondialysis-chronic-kidney-disease
bull Chan M Dall A T Fletcher K E Lu N amp Trivedi H (2007) Outcomes in patients with chronic kidney disease referred late to nephrologists a meta-analysis American Journal of Medicine 120(12) 1063-1070
bull Coresh J Selvin E amp Stevens L A (2007) Prevalence of chronic kidny disease in the United States JAMA 298(17) doi101001jama298172038
bull de Brito-Ashurst I Varagunam M Raftery M amp Yagoob M (2009) Bicarbonate supplementation slows progression of CKD and improves nutritional status Journal of American Society of Nephrology (20) 2075-2084
BIBLIOGRAPHY
bull Duncan L Heathcoat J Djurdjev O amp Levin A (2001) Screening for renal disease using serum creatinine who are we missing Nephrology Dialysis and Transplant 16(5) 1042-1046
bull Dunkler D Gao P Lee S F Heinz G Clase C M Tobe S Oberbauer R (2015 August 7) Risk prediction for early CKD in type 2 diabetes Retrieved from Clinical Journal of the American Society of Nephrology httpcjasnasnjournalsorgcontent1081371fullsid=61422554-a5f1-41ac-b696-dcd3b12bd268
bull Fatehi P amp Chi-yuan H (September 15 2016) Diagnostic approach to the patient with newly identified chronic kidney disease (G C Curhan amp A M Sheridan Eds) Retrieved May 7 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsdiagnostic-approach-to-the-patient-with-newly-identified-chronic-kidney-disease
bull Fink J e (2009) Chronic Kidney Disease as an Under-Recognized Threat to Patient Safety American journal of kidney diseases the official journal of the National Kidney Foundation 53(4) 681-688
bull Gaffo A L amp Saag K G (2008 Nov) Management of hyperuricemia and gout in CKD doihttpdxdoiorg101053jajkd200807035
bull Hebert L A amp Parikh S V (2014 June 18) Differential diagnosis and evaluation of glomerular disease (R J Glassock amp A Q Lam Eds) Retrieved May 7 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsdifferential-diagnosis-and-evaluation-of-glomerular-disease
bull Inker L Perrone R D Sterns R H amp Forman J P (2017 March 7) Assessment of kidney function Retrieved from UpToDate httpswww-uptodate-comproxywichitaeducontentsassessment-of-kidney-functionsource=search_resultampsearch=creatinineampselectedTitle=1~150
BIBLIOGRAPHY
bull James P A Ortiz E amp Et Al (2014) Evidence based guideline for the management of high blood pressure in adults (JNC) JAMA 311(5) 507-520
bull Kidney Disease Improving Global Outcomes (KDIGO) CKD Work Group (2013 January) KDIGO 2012 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease Retrieved from Kidney International Supplement httpwwwkidney-internationalorg
bull Kunz R Friedrich C Wolbers M amp Mann J F (2008) Meta-analysis effect of monotherapy and combination therapy with inhibitors of the renin angiotensin system on proteinuria in renal disease Annals of Internal Medicine 148(1) 30-48
bull Levey A Stevens L A Schmid C H Castro A F Feldman H I Kusek J W Coresh J (2009) A new equation to estimate glomerular filtration rate Annals of Internal Medicine 150(9) 604-612
bull Levin A Bakris G L Molitch M Smulders M M Williams L A amp Andress D L (2007 Jan) Prevalence of abnormal serum vitamin D PTH calcium and phosphorus in patients with chronic kidney disease results of the study to evaluate early kidney disease Kidney International 71(1) 31-38 Retrieved from PubMED
bull Mahajan A Simoni J Sheather S Broglio K Rajab M amp Wesson D (2010) Daily oral sodium bicarbonate preserves glomerular filtration rate by slowing its decline in early hypertensive nephropathy Kidney International (78_ 303-309
bull Mann J Schmieder R E amp McQueen M (2008) Renal outcomes with telmisartan ramipril or both in people at high vascular risk (the ONTARGET study) a multicentre randomised doubleblind ocntrolled trial Lancet 372(9638) 547-533
BIBLIOGRAPHY
bull Matovinović M S (2009) Pathophysiology and classification of kidney disease Retrieved from The Journal of the International Federation of Clinical Chemistry and Laboratory Medicine httpwwwifccorgifccfilesdocs20010902pdf
bull Moe S Drueke T Lameire N amp Eknoyan G (2007 Jan) Chronic kidney disease-mineral-bone disorder a new paradigmdoi101053jackd200610005
bull Murtagh F E Marsh J E Donohoe P Ekbal N J Sheerin N S amp Harris F E (2007 July) Dialysis or not A comparative survival study of patients over 75 years with chronic kidney disease stage 5 Retrieved from Nephrology Dialysis and Transplant 22(7) httpswwwncbinlmnihgovpubmed17412702
bull National Kidney Foundation (2002) KDOQI clinical practice guidelines for chronic kidney disease evaluation classification andstratification American Journal of Kidney Disease S1-S266
bull National Kidney Foundation (2014 November 5) Fact Sheets Retrieved from httpwwwkidneyorgnewsnewsroomfactsheetsFastFacts
bull Pal S (2012 June 2) Trends in chronic kidney disease Retrieved from US Pharmacist (37)6 httpswwwuspharmacistcomarticletrends-in-chronic-kidney-disease
bull Qunibi W amp Henrich W L (2017 Jan 19) Overview of chronic kidney disease-mineral and bone disorder (J Berns amp A M Sheridan Eds) Retrieved from UpToDate httpswww-uptodate-comoverview-of-chronic-kidney-disease-mineral-and-bone-disorder-ckd-mbd
bull Rosenberg M (2016 Feb 24) Overview of the management of chronic kidney disease in adults (G C Curhan amp A M Sheridan Eds) Retrieved from UpToDate UpToDate httpswww-uptodate-comproxywichitaeducontentsoverview-of-the-management-of-chronic-kidney-disease-in-adults
BIBLIOGRAPHY
bull Szczech L Stewart R C Hsu-Lin S DeLosky R J Astor B C Fox C H Vassalotti J A (2014) Primary care detection of chronic kidney disease in adults with type 2 diabetes The ADD-CKD Study (Awareness Detection and Drug Therapy in type 2 diabetes and chronic kidney disease PLOS doihttpsdoiorg101371journalpone0110535
bull USRDS (2016) Annual data report 2016 Epidemiology of kidney disease in the United States Retrieved from United States Renal Data System httpswwwusrdsorgadraspx
bull Vasudev B amp Vasudev M (2012) A model curriculum for residents rotating in nephrology MedEDPORTAL doihttpdoiorg1015766mep_2374-82658288
bull Wei L MacDonald T M Jennings C Sheng X amp Flynn R W (2013) Estimated GFR reporting is associated with decreased nonsteroidal anti-inflammatory drug prescribing and increased renal function Kidney International (84)1 174-178
chronic kidney disease in primary care
CKD as a Public Health Issue
Slide Number 3
Costs of CKD in 2013 dollarsUSRDS report
Steps to CKD Patient Care
Renal anatomy and physiology
Definition of Chronic Kidney Disease
CKD Risk Factors
Gaps in CKD Diagnosis
Slide Number 10
Steps to CKD Patient Care
creatinine
Glomerular filtration rate
Slide Number 14
Slide Number 15
Use These Equations Cautiously if at all in hellip
lab albumin creatinine ratio
The New CKD Categories
Steps to CKD Patient Care
Slide Number 20
Kidney Involvement in Systemic Diseases
Slide Number 22
Slide Number 23
DysmorphicRenal Hematuria
Slide Number 25
If you have albuminuria or hematuria-order the following labs
bull Progression of disease ndash declining eGFR increasing proteinuria
bull Degree of proteinuria nephrotic syndrome gt 05-10 gd on ACEi or ARB therapy
bull Etiology of CKD not certain
bull Need help with disease management
bull Indications for kidney biopsy
Rosenberg 2016
WHEN TO REFER
STEPS TO CKD PATIENT CARE
1 CKD definition and risks2 Assess GFR albuminuria3 Determine etiology4 Assess for evidence of progression5 Assess for associated complications6 Discuss dialysistransplantation
KIDNEY TRANSPLANTATION
bull Treatment of choice for ESRDbull Improves quality of lifebull Waiting list time varies-3-5 yearsbull 3 year survival rate after transplantation is 83-94bull Increased risk of cancer
STARTING DIALYSIS IN THE ELDERLYhellipOR NOT
bull Among patients gt 75 yrs with stage 5 CKD who chose to NOT start dialysisbull Overall more likely to die over next 1-2 years bull But if they had ischemic heart disease or other significant comorbidity NO
DIFFERENCE in survival
bull Active disease management and supportive care may be appropriate without starting dialysis in the ill elderly
bull Palliative care does not mean ldquono carerdquo
bull Must have end-of-life discussions
(Murtagh et al 2007)
CKD MANAGEMENTbull Diagnose cause and treat underlying conditionbull Stage per guidelinesbull Slow progression of kidney disease (ACE inhibitors)bull Monitor for complicationsmdashvolume overload hyperkalemia metabolic acidosis
hyperphosphatemia anorexia fatigue htn bone diseasebull Labs cmp cbc phos Vit D 25OH iPTH urine microscopy uric acid urine
proteincr ratio-frequency based off heat map Get sono at least oncebull Vaccinate influenza hep B pneumococcalbull Eval ASCVD risk-likely needs statinbull Possible dexa (donrsquot give bisphosphonates if GFRlt35 let specialist manage)bull Refer to nephrology when eGFR is lt30 (sometimes if higher risk-refer earlier)
CASE 1
bull 55 year old man with past medical history of headaches presents to your office for his first time visit to a PCP in over 30 years
bull He has no past history of being admitted to the hospital and he does not take any OTC medsNSAIDsherbal meds He has no history of ETOH abuse smoking or drug use
bull Vitals BP 180100 mmHg pulse 80 R 18
bull Exam No JVD S1S2 regular PMI shifted to the left no gallop no abdominal bruit pulses bilaterally equal and regular no leg edema
bull What would you order
bull EKG cbc cmp ua urine proteincr ratio lipid
LAB RESULTS
bull Labs reveal a creatinine of 22 mgdL eGFR 33 Urine shows no blood or casts Urineprotein ratio shows 1 gm protein24 hrs EKG shows LVH
bull Next step in workupbull Renal ultrasound 1st then SPEP UPEP with immunofixation serum free light chains
bull Additional labs neg Renal ultrasound shows that both kidneys are slightly reduced in size and are mildly echogenic with no mass or hydronephrosis
bull What is your diagnosis
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileMain_complications_of_persistent_high_blood_pressurepngCreative Commons License associated httpcreativecommonsorglicensesby-sa30
bull 3 months Howevermdashwe have evidence of structural abnormalities Could potentially stage at G3b A3 (red on the heat map)
bull Goal blood pressure
bull JNC 8 14090 NKF 13080
bull Additional lab needed for progression monitoring
bull Cbc renal panel phos Vit D iPTH uric acid urine micro (we already have the renal sono and urine proteincr ratio and lipid)
Selective renal angiography (left lower renal artery) after successful percutaneous balloon dilatation of the stenotic lesionFibromuscular dysplasia in an accessory renal artery causing renovascular hypertension
Secondary Hypertension
Images retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileRenal_FMD2jpg and httpcommonswikimediaorgwikiFileRenal_FMDjpgCreative Commons License associated httpcreativecommonsorglicensesby20deeden (both images)
CASE 2bull OS is a 64year old Hispanic female in for DM check She has had DM for 15+ years and is currently
taking metformin 1000mg bid Lisinopril 10mg a day atorvastatin 40mg a day Labs today showed the following
bull Hgba1c 86 cmp eGFR 50 lipid WNL proteincr ratio 650mg These results are similar to her last visit
bull Upon further hx-you find that she had a recent eye exam and has mild nonproliferaive retinopathy She does not have neuropathy or other ss
bull What further workup do you need
bull Renal sonogram urine micro iPTH vit D (25 OH) phos uric acid
bull Dx stage
bull G3a A3
bull What further treatment do you need
bull Improve glycemic control Increase Lisinopril to 20mg with a goal of 40mg Avoid NSAIDs or other nephrotoxic agents make sure meds are renally dosed monitor 3xyear nephro referral
MANAGEMENT OF CKD IN DIABETESeGFR Recommended
All patients
Yearly measurement of creatinine urinary albumin excretion potassium
45-60 Referral to a nephrologist if possibility for nondiabetickidney disease existsConsider dose adjustment of medicationsMonitor eGFR every 6 monthsMonitor electrolytes bicarbonate hemoglobin calcium phosphorus parathyroid hormone at least yearly
Assure vitamin D sufficiencyConsider bone density testingReferral for dietary counselling
American Diabetes Association Standards of Medical Care in Diabetes Microvascular complications and foot care Diabetes Care 2017 40 (Suppl 1) S88-S98
CASE 3
bull 19 year old African American woman presents to your clinic with complaints of fatigue joint pains a new rash on her face oral ulcer
bull On exam BP 15080 P 88 Afebrile 96 O2 sats on RAbull GEN No respiratory distress at restbull HEENT painless oral ulcer flat rash over malar eminences sparing the nasolabial fold pallor +bull Lungs CTAbull CVS S1S2 regularbull Abdomen soft NTbull Ext left elbow joint and bilateral wrist joints are swollen and tender
bull What would you orderbull CBC CMP ua urine microscopy (microalbumin or urine proteincr ratio) ANA esr RF anti-ccp uric acid TSH
CASE 3
bull Working dx fatigue oral ulcer joint pain
bull Basic Labs Na 135 K 55 Bicarb 18 BUN 50 Cr 35 eGFR 22 Ca 90 ANA + titer 1640
bull UA 3+ blood 3+ protein RBC casts +
bull Given these results what is the most likely diagnosis
bull What would you do
SYSTEMIC LUPUS ERYTHEMATOSUS (SLE)
bull SLE multisystemic disease Etiology unknown
bull Production of autoantibodies and immune complexes formation
bull There is renal involvement in the great majority of patients with SLE at some time of the evolution 66-90
SLE ndash LUPUS NEPHRITIS
bull Race SLE is more commonsevere in African americans than Caucasiansbull
bull Gender female-to-male ratio of 91
bull Age Most patients develop lupus nephritis early in their disease course SLE is more common among women in the third decade of life and lupus nephritis occurs in patients aged 20-40 years
bull Kidney Biopsy For staging lupus nephritis (Class 1-5)
CASE 5bull A 80 year old man who has not seen a PCP in many years
presents to your clinic for weakness for the past few months On further questioning he tells you that his bones also have been hurting lately and he has developed leg swelling in the past month or so
bull On exam bull BP 16090 P 88 Afebrilebull GEN Thin built manbull HEENT pallor presentbull Lungs clearbull CVS S1S2 regular no rub or gallopbull Abdomen soft NTbull Ext 2 + edema
CASE 5
bull Differentials
bull CHF MI Cancer arthritis
bull Labs
bull CBC CMP urine microscopy urine proteincr ratio ESR TSH EKG BNP pa and lat CXR
bull LABS Urine dipstick negative for protein or blood
bull Basic chem bull Na 136 (135-145) K 51 (35-55) Chloride 108 (96-106) Bicarb 25
Given this presentation and the labs (low anion gap and elevated calcium anemia kidney failure) what will you think of What will you order next
Serum and urine protein electrophoresis
Intratubular refractile casts with surrounding syncytial giant cell reaction with chronic tubulointerstitial nephritis and fibrosis characteristic of myeloma cast nephropathy
Kidney Biopsy
CASE STUDYbull A 35 year old African American woman was seen in the clinic for
chronic cough and dyspnea on exertion She gave history of vague symptoms of fatigue and weight loss of 20 Ibs over the last six months
bull List some differentialsbull TB sarcoid lupus thyroid problems PEbull What would you orderbull PPD cbc cmp UA TSH ANA pa and lat cxr
bull Her labs were significant for mildly elevated calcium level and a creatinine of 20 mgdL eGFR 37
bull She had 750 mg of proteinuriaday
bull PPD neg ANA neg TSH and other labs WNL
bull Assuming this is present more than 3 monthshelliphellipwhat is her ckd stage
bull G3b A3
bull What do we still need
CT scan of chest
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileAnterior_mediastinal_mass_thymomajpgCreative Commons License associated httpcreativecommonsorglicensesby20deeden
CXR ndash HILAR LYMPHADENOPATHY
WHATS NEEDED NEXT
bull Biopsy of hilar lymphadenopathy or renal biopsy
bull DX sarcoidosis
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileSarcoidosis_signs_and_symptomsjpgThis work is in the public domain in the United States because it is a work of the United States Federal Government under the terms of Title 17 Chapter 1 Section 105 of the US Code
NEWLY DX CKD
bull 1) urinalysis microscopy ultrasound proteincr ratio
bull If obstruction-treat
bull No obstruction
bull Hx critical (consider myeloma if high risk)
bull glomerular bleeding or albumin in urine
bull Yes workup for glomerular causes (ANArf hep B C upep spep ANCA complement C3 C4)
bull No sterile pyruria-consider interstitial nephritis
bull High risk renovascular disease Evaluate renovascular disease
Additional Online Resources for CKD LearningbullNational Kidney Foundation wwwkidneyorgbullUnited States Renal Data Service wwwusrdsorgbullCDCrsquos CKD Surveillance Project
httpnccdcdcgovckdbullNational Kidney Disease Education Program
(NKDEP) httpnkdepnihgov
BIBLIOGRAPHY
bull Afzali B amp Goldsmith D J (2016 June 29) Statins and chronic kidney disease (G C Curhan amp A M Sheridan Eds) Retrieved 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsstatins-and-chronic-kidney-disease
bull American Diabetes Association Standards of Medical Care in Diabetes (2017) Microvascular complications and foot care Diabetes Care 2017 (40) S88-S98
bull American Diabetes Association Standards of Medical Care in Diabetes (2017) Microvascular complications and foot care Diabetes Care 40 (suppl 1) S88-S98
bull Berns J S (2017 Mar 22) Treatment of anemia in nondialysis chronic kidney disease (T A Golper amp A M Sheridan Eds) Retrieved from UpToDate httpswww-uptodate-comproxywichitaeducontentstreatment-of-anemia-in-nondialysis-chronic-kidney-disease
bull Chan M Dall A T Fletcher K E Lu N amp Trivedi H (2007) Outcomes in patients with chronic kidney disease referred late to nephrologists a meta-analysis American Journal of Medicine 120(12) 1063-1070
bull Coresh J Selvin E amp Stevens L A (2007) Prevalence of chronic kidny disease in the United States JAMA 298(17) doi101001jama298172038
bull de Brito-Ashurst I Varagunam M Raftery M amp Yagoob M (2009) Bicarbonate supplementation slows progression of CKD and improves nutritional status Journal of American Society of Nephrology (20) 2075-2084
BIBLIOGRAPHY
bull Duncan L Heathcoat J Djurdjev O amp Levin A (2001) Screening for renal disease using serum creatinine who are we missing Nephrology Dialysis and Transplant 16(5) 1042-1046
bull Dunkler D Gao P Lee S F Heinz G Clase C M Tobe S Oberbauer R (2015 August 7) Risk prediction for early CKD in type 2 diabetes Retrieved from Clinical Journal of the American Society of Nephrology httpcjasnasnjournalsorgcontent1081371fullsid=61422554-a5f1-41ac-b696-dcd3b12bd268
bull Fatehi P amp Chi-yuan H (September 15 2016) Diagnostic approach to the patient with newly identified chronic kidney disease (G C Curhan amp A M Sheridan Eds) Retrieved May 7 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsdiagnostic-approach-to-the-patient-with-newly-identified-chronic-kidney-disease
bull Fink J e (2009) Chronic Kidney Disease as an Under-Recognized Threat to Patient Safety American journal of kidney diseases the official journal of the National Kidney Foundation 53(4) 681-688
bull Gaffo A L amp Saag K G (2008 Nov) Management of hyperuricemia and gout in CKD doihttpdxdoiorg101053jajkd200807035
bull Hebert L A amp Parikh S V (2014 June 18) Differential diagnosis and evaluation of glomerular disease (R J Glassock amp A Q Lam Eds) Retrieved May 7 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsdifferential-diagnosis-and-evaluation-of-glomerular-disease
bull Inker L Perrone R D Sterns R H amp Forman J P (2017 March 7) Assessment of kidney function Retrieved from UpToDate httpswww-uptodate-comproxywichitaeducontentsassessment-of-kidney-functionsource=search_resultampsearch=creatinineampselectedTitle=1~150
BIBLIOGRAPHY
bull James P A Ortiz E amp Et Al (2014) Evidence based guideline for the management of high blood pressure in adults (JNC) JAMA 311(5) 507-520
bull Kidney Disease Improving Global Outcomes (KDIGO) CKD Work Group (2013 January) KDIGO 2012 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease Retrieved from Kidney International Supplement httpwwwkidney-internationalorg
bull Kunz R Friedrich C Wolbers M amp Mann J F (2008) Meta-analysis effect of monotherapy and combination therapy with inhibitors of the renin angiotensin system on proteinuria in renal disease Annals of Internal Medicine 148(1) 30-48
bull Levey A Stevens L A Schmid C H Castro A F Feldman H I Kusek J W Coresh J (2009) A new equation to estimate glomerular filtration rate Annals of Internal Medicine 150(9) 604-612
bull Levin A Bakris G L Molitch M Smulders M M Williams L A amp Andress D L (2007 Jan) Prevalence of abnormal serum vitamin D PTH calcium and phosphorus in patients with chronic kidney disease results of the study to evaluate early kidney disease Kidney International 71(1) 31-38 Retrieved from PubMED
bull Mahajan A Simoni J Sheather S Broglio K Rajab M amp Wesson D (2010) Daily oral sodium bicarbonate preserves glomerular filtration rate by slowing its decline in early hypertensive nephropathy Kidney International (78_ 303-309
bull Mann J Schmieder R E amp McQueen M (2008) Renal outcomes with telmisartan ramipril or both in people at high vascular risk (the ONTARGET study) a multicentre randomised doubleblind ocntrolled trial Lancet 372(9638) 547-533
BIBLIOGRAPHY
bull Matovinović M S (2009) Pathophysiology and classification of kidney disease Retrieved from The Journal of the International Federation of Clinical Chemistry and Laboratory Medicine httpwwwifccorgifccfilesdocs20010902pdf
bull Moe S Drueke T Lameire N amp Eknoyan G (2007 Jan) Chronic kidney disease-mineral-bone disorder a new paradigmdoi101053jackd200610005
bull Murtagh F E Marsh J E Donohoe P Ekbal N J Sheerin N S amp Harris F E (2007 July) Dialysis or not A comparative survival study of patients over 75 years with chronic kidney disease stage 5 Retrieved from Nephrology Dialysis and Transplant 22(7) httpswwwncbinlmnihgovpubmed17412702
bull National Kidney Foundation (2002) KDOQI clinical practice guidelines for chronic kidney disease evaluation classification andstratification American Journal of Kidney Disease S1-S266
bull National Kidney Foundation (2014 November 5) Fact Sheets Retrieved from httpwwwkidneyorgnewsnewsroomfactsheetsFastFacts
bull Pal S (2012 June 2) Trends in chronic kidney disease Retrieved from US Pharmacist (37)6 httpswwwuspharmacistcomarticletrends-in-chronic-kidney-disease
bull Qunibi W amp Henrich W L (2017 Jan 19) Overview of chronic kidney disease-mineral and bone disorder (J Berns amp A M Sheridan Eds) Retrieved from UpToDate httpswww-uptodate-comoverview-of-chronic-kidney-disease-mineral-and-bone-disorder-ckd-mbd
bull Rosenberg M (2016 Feb 24) Overview of the management of chronic kidney disease in adults (G C Curhan amp A M Sheridan Eds) Retrieved from UpToDate UpToDate httpswww-uptodate-comproxywichitaeducontentsoverview-of-the-management-of-chronic-kidney-disease-in-adults
BIBLIOGRAPHY
bull Szczech L Stewart R C Hsu-Lin S DeLosky R J Astor B C Fox C H Vassalotti J A (2014) Primary care detection of chronic kidney disease in adults with type 2 diabetes The ADD-CKD Study (Awareness Detection and Drug Therapy in type 2 diabetes and chronic kidney disease PLOS doihttpsdoiorg101371journalpone0110535
bull USRDS (2016) Annual data report 2016 Epidemiology of kidney disease in the United States Retrieved from United States Renal Data System httpswwwusrdsorgadraspx
bull Vasudev B amp Vasudev M (2012) A model curriculum for residents rotating in nephrology MedEDPORTAL doihttpdoiorg1015766mep_2374-82658288
bull Wei L MacDonald T M Jennings C Sheng X amp Flynn R W (2013) Estimated GFR reporting is associated with decreased nonsteroidal anti-inflammatory drug prescribing and increased renal function Kidney International (84)1 174-178
chronic kidney disease in primary care
CKD as a Public Health Issue
Slide Number 3
Costs of CKD in 2013 dollarsUSRDS report
Steps to CKD Patient Care
Renal anatomy and physiology
Definition of Chronic Kidney Disease
CKD Risk Factors
Gaps in CKD Diagnosis
Slide Number 10
Steps to CKD Patient Care
creatinine
Glomerular filtration rate
Slide Number 14
Slide Number 15
Use These Equations Cautiously if at all in hellip
lab albumin creatinine ratio
The New CKD Categories
Steps to CKD Patient Care
Slide Number 20
Kidney Involvement in Systemic Diseases
Slide Number 22
Slide Number 23
DysmorphicRenal Hematuria
Slide Number 25
If you have albuminuria or hematuria-order the following labs
bull Progression of disease ndash declining eGFR increasing proteinuria
bull Degree of proteinuria nephrotic syndrome gt 05-10 gd on ACEi or ARB therapy
bull Etiology of CKD not certain
bull Need help with disease management
bull Indications for kidney biopsy
Rosenberg 2016
WHEN TO REFER
STEPS TO CKD PATIENT CARE
1 CKD definition and risks2 Assess GFR albuminuria3 Determine etiology4 Assess for evidence of progression5 Assess for associated complications6 Discuss dialysistransplantation
KIDNEY TRANSPLANTATION
bull Treatment of choice for ESRDbull Improves quality of lifebull Waiting list time varies-3-5 yearsbull 3 year survival rate after transplantation is 83-94bull Increased risk of cancer
STARTING DIALYSIS IN THE ELDERLYhellipOR NOT
bull Among patients gt 75 yrs with stage 5 CKD who chose to NOT start dialysisbull Overall more likely to die over next 1-2 years bull But if they had ischemic heart disease or other significant comorbidity NO
DIFFERENCE in survival
bull Active disease management and supportive care may be appropriate without starting dialysis in the ill elderly
bull Palliative care does not mean ldquono carerdquo
bull Must have end-of-life discussions
(Murtagh et al 2007)
CKD MANAGEMENTbull Diagnose cause and treat underlying conditionbull Stage per guidelinesbull Slow progression of kidney disease (ACE inhibitors)bull Monitor for complicationsmdashvolume overload hyperkalemia metabolic acidosis
hyperphosphatemia anorexia fatigue htn bone diseasebull Labs cmp cbc phos Vit D 25OH iPTH urine microscopy uric acid urine
proteincr ratio-frequency based off heat map Get sono at least oncebull Vaccinate influenza hep B pneumococcalbull Eval ASCVD risk-likely needs statinbull Possible dexa (donrsquot give bisphosphonates if GFRlt35 let specialist manage)bull Refer to nephrology when eGFR is lt30 (sometimes if higher risk-refer earlier)
CASE 1
bull 55 year old man with past medical history of headaches presents to your office for his first time visit to a PCP in over 30 years
bull He has no past history of being admitted to the hospital and he does not take any OTC medsNSAIDsherbal meds He has no history of ETOH abuse smoking or drug use
bull Vitals BP 180100 mmHg pulse 80 R 18
bull Exam No JVD S1S2 regular PMI shifted to the left no gallop no abdominal bruit pulses bilaterally equal and regular no leg edema
bull What would you order
bull EKG cbc cmp ua urine proteincr ratio lipid
LAB RESULTS
bull Labs reveal a creatinine of 22 mgdL eGFR 33 Urine shows no blood or casts Urineprotein ratio shows 1 gm protein24 hrs EKG shows LVH
bull Next step in workupbull Renal ultrasound 1st then SPEP UPEP with immunofixation serum free light chains
bull Additional labs neg Renal ultrasound shows that both kidneys are slightly reduced in size and are mildly echogenic with no mass or hydronephrosis
bull What is your diagnosis
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileMain_complications_of_persistent_high_blood_pressurepngCreative Commons License associated httpcreativecommonsorglicensesby-sa30
bull 3 months Howevermdashwe have evidence of structural abnormalities Could potentially stage at G3b A3 (red on the heat map)
bull Goal blood pressure
bull JNC 8 14090 NKF 13080
bull Additional lab needed for progression monitoring
bull Cbc renal panel phos Vit D iPTH uric acid urine micro (we already have the renal sono and urine proteincr ratio and lipid)
Selective renal angiography (left lower renal artery) after successful percutaneous balloon dilatation of the stenotic lesionFibromuscular dysplasia in an accessory renal artery causing renovascular hypertension
Secondary Hypertension
Images retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileRenal_FMD2jpg and httpcommonswikimediaorgwikiFileRenal_FMDjpgCreative Commons License associated httpcreativecommonsorglicensesby20deeden (both images)
CASE 2bull OS is a 64year old Hispanic female in for DM check She has had DM for 15+ years and is currently
taking metformin 1000mg bid Lisinopril 10mg a day atorvastatin 40mg a day Labs today showed the following
bull Hgba1c 86 cmp eGFR 50 lipid WNL proteincr ratio 650mg These results are similar to her last visit
bull Upon further hx-you find that she had a recent eye exam and has mild nonproliferaive retinopathy She does not have neuropathy or other ss
bull What further workup do you need
bull Renal sonogram urine micro iPTH vit D (25 OH) phos uric acid
bull Dx stage
bull G3a A3
bull What further treatment do you need
bull Improve glycemic control Increase Lisinopril to 20mg with a goal of 40mg Avoid NSAIDs or other nephrotoxic agents make sure meds are renally dosed monitor 3xyear nephro referral
MANAGEMENT OF CKD IN DIABETESeGFR Recommended
All patients
Yearly measurement of creatinine urinary albumin excretion potassium
45-60 Referral to a nephrologist if possibility for nondiabetickidney disease existsConsider dose adjustment of medicationsMonitor eGFR every 6 monthsMonitor electrolytes bicarbonate hemoglobin calcium phosphorus parathyroid hormone at least yearly
Assure vitamin D sufficiencyConsider bone density testingReferral for dietary counselling
American Diabetes Association Standards of Medical Care in Diabetes Microvascular complications and foot care Diabetes Care 2017 40 (Suppl 1) S88-S98
CASE 3
bull 19 year old African American woman presents to your clinic with complaints of fatigue joint pains a new rash on her face oral ulcer
bull On exam BP 15080 P 88 Afebrile 96 O2 sats on RAbull GEN No respiratory distress at restbull HEENT painless oral ulcer flat rash over malar eminences sparing the nasolabial fold pallor +bull Lungs CTAbull CVS S1S2 regularbull Abdomen soft NTbull Ext left elbow joint and bilateral wrist joints are swollen and tender
bull What would you orderbull CBC CMP ua urine microscopy (microalbumin or urine proteincr ratio) ANA esr RF anti-ccp uric acid TSH
CASE 3
bull Working dx fatigue oral ulcer joint pain
bull Basic Labs Na 135 K 55 Bicarb 18 BUN 50 Cr 35 eGFR 22 Ca 90 ANA + titer 1640
bull UA 3+ blood 3+ protein RBC casts +
bull Given these results what is the most likely diagnosis
bull What would you do
SYSTEMIC LUPUS ERYTHEMATOSUS (SLE)
bull SLE multisystemic disease Etiology unknown
bull Production of autoantibodies and immune complexes formation
bull There is renal involvement in the great majority of patients with SLE at some time of the evolution 66-90
SLE ndash LUPUS NEPHRITIS
bull Race SLE is more commonsevere in African americans than Caucasiansbull
bull Gender female-to-male ratio of 91
bull Age Most patients develop lupus nephritis early in their disease course SLE is more common among women in the third decade of life and lupus nephritis occurs in patients aged 20-40 years
bull Kidney Biopsy For staging lupus nephritis (Class 1-5)
CASE 5bull A 80 year old man who has not seen a PCP in many years
presents to your clinic for weakness for the past few months On further questioning he tells you that his bones also have been hurting lately and he has developed leg swelling in the past month or so
bull On exam bull BP 16090 P 88 Afebrilebull GEN Thin built manbull HEENT pallor presentbull Lungs clearbull CVS S1S2 regular no rub or gallopbull Abdomen soft NTbull Ext 2 + edema
CASE 5
bull Differentials
bull CHF MI Cancer arthritis
bull Labs
bull CBC CMP urine microscopy urine proteincr ratio ESR TSH EKG BNP pa and lat CXR
bull LABS Urine dipstick negative for protein or blood
bull Basic chem bull Na 136 (135-145) K 51 (35-55) Chloride 108 (96-106) Bicarb 25
Given this presentation and the labs (low anion gap and elevated calcium anemia kidney failure) what will you think of What will you order next
Serum and urine protein electrophoresis
Intratubular refractile casts with surrounding syncytial giant cell reaction with chronic tubulointerstitial nephritis and fibrosis characteristic of myeloma cast nephropathy
Kidney Biopsy
CASE STUDYbull A 35 year old African American woman was seen in the clinic for
chronic cough and dyspnea on exertion She gave history of vague symptoms of fatigue and weight loss of 20 Ibs over the last six months
bull List some differentialsbull TB sarcoid lupus thyroid problems PEbull What would you orderbull PPD cbc cmp UA TSH ANA pa and lat cxr
bull Her labs were significant for mildly elevated calcium level and a creatinine of 20 mgdL eGFR 37
bull She had 750 mg of proteinuriaday
bull PPD neg ANA neg TSH and other labs WNL
bull Assuming this is present more than 3 monthshelliphellipwhat is her ckd stage
bull G3b A3
bull What do we still need
CT scan of chest
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileAnterior_mediastinal_mass_thymomajpgCreative Commons License associated httpcreativecommonsorglicensesby20deeden
CXR ndash HILAR LYMPHADENOPATHY
WHATS NEEDED NEXT
bull Biopsy of hilar lymphadenopathy or renal biopsy
bull DX sarcoidosis
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileSarcoidosis_signs_and_symptomsjpgThis work is in the public domain in the United States because it is a work of the United States Federal Government under the terms of Title 17 Chapter 1 Section 105 of the US Code
NEWLY DX CKD
bull 1) urinalysis microscopy ultrasound proteincr ratio
bull If obstruction-treat
bull No obstruction
bull Hx critical (consider myeloma if high risk)
bull glomerular bleeding or albumin in urine
bull Yes workup for glomerular causes (ANArf hep B C upep spep ANCA complement C3 C4)
bull No sterile pyruria-consider interstitial nephritis
bull High risk renovascular disease Evaluate renovascular disease
Additional Online Resources for CKD LearningbullNational Kidney Foundation wwwkidneyorgbullUnited States Renal Data Service wwwusrdsorgbullCDCrsquos CKD Surveillance Project
httpnccdcdcgovckdbullNational Kidney Disease Education Program
(NKDEP) httpnkdepnihgov
BIBLIOGRAPHY
bull Afzali B amp Goldsmith D J (2016 June 29) Statins and chronic kidney disease (G C Curhan amp A M Sheridan Eds) Retrieved 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsstatins-and-chronic-kidney-disease
bull American Diabetes Association Standards of Medical Care in Diabetes (2017) Microvascular complications and foot care Diabetes Care 2017 (40) S88-S98
bull American Diabetes Association Standards of Medical Care in Diabetes (2017) Microvascular complications and foot care Diabetes Care 40 (suppl 1) S88-S98
bull Berns J S (2017 Mar 22) Treatment of anemia in nondialysis chronic kidney disease (T A Golper amp A M Sheridan Eds) Retrieved from UpToDate httpswww-uptodate-comproxywichitaeducontentstreatment-of-anemia-in-nondialysis-chronic-kidney-disease
bull Chan M Dall A T Fletcher K E Lu N amp Trivedi H (2007) Outcomes in patients with chronic kidney disease referred late to nephrologists a meta-analysis American Journal of Medicine 120(12) 1063-1070
bull Coresh J Selvin E amp Stevens L A (2007) Prevalence of chronic kidny disease in the United States JAMA 298(17) doi101001jama298172038
bull de Brito-Ashurst I Varagunam M Raftery M amp Yagoob M (2009) Bicarbonate supplementation slows progression of CKD and improves nutritional status Journal of American Society of Nephrology (20) 2075-2084
BIBLIOGRAPHY
bull Duncan L Heathcoat J Djurdjev O amp Levin A (2001) Screening for renal disease using serum creatinine who are we missing Nephrology Dialysis and Transplant 16(5) 1042-1046
bull Dunkler D Gao P Lee S F Heinz G Clase C M Tobe S Oberbauer R (2015 August 7) Risk prediction for early CKD in type 2 diabetes Retrieved from Clinical Journal of the American Society of Nephrology httpcjasnasnjournalsorgcontent1081371fullsid=61422554-a5f1-41ac-b696-dcd3b12bd268
bull Fatehi P amp Chi-yuan H (September 15 2016) Diagnostic approach to the patient with newly identified chronic kidney disease (G C Curhan amp A M Sheridan Eds) Retrieved May 7 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsdiagnostic-approach-to-the-patient-with-newly-identified-chronic-kidney-disease
bull Fink J e (2009) Chronic Kidney Disease as an Under-Recognized Threat to Patient Safety American journal of kidney diseases the official journal of the National Kidney Foundation 53(4) 681-688
bull Gaffo A L amp Saag K G (2008 Nov) Management of hyperuricemia and gout in CKD doihttpdxdoiorg101053jajkd200807035
bull Hebert L A amp Parikh S V (2014 June 18) Differential diagnosis and evaluation of glomerular disease (R J Glassock amp A Q Lam Eds) Retrieved May 7 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsdifferential-diagnosis-and-evaluation-of-glomerular-disease
bull Inker L Perrone R D Sterns R H amp Forman J P (2017 March 7) Assessment of kidney function Retrieved from UpToDate httpswww-uptodate-comproxywichitaeducontentsassessment-of-kidney-functionsource=search_resultampsearch=creatinineampselectedTitle=1~150
BIBLIOGRAPHY
bull James P A Ortiz E amp Et Al (2014) Evidence based guideline for the management of high blood pressure in adults (JNC) JAMA 311(5) 507-520
bull Kidney Disease Improving Global Outcomes (KDIGO) CKD Work Group (2013 January) KDIGO 2012 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease Retrieved from Kidney International Supplement httpwwwkidney-internationalorg
bull Kunz R Friedrich C Wolbers M amp Mann J F (2008) Meta-analysis effect of monotherapy and combination therapy with inhibitors of the renin angiotensin system on proteinuria in renal disease Annals of Internal Medicine 148(1) 30-48
bull Levey A Stevens L A Schmid C H Castro A F Feldman H I Kusek J W Coresh J (2009) A new equation to estimate glomerular filtration rate Annals of Internal Medicine 150(9) 604-612
bull Levin A Bakris G L Molitch M Smulders M M Williams L A amp Andress D L (2007 Jan) Prevalence of abnormal serum vitamin D PTH calcium and phosphorus in patients with chronic kidney disease results of the study to evaluate early kidney disease Kidney International 71(1) 31-38 Retrieved from PubMED
bull Mahajan A Simoni J Sheather S Broglio K Rajab M amp Wesson D (2010) Daily oral sodium bicarbonate preserves glomerular filtration rate by slowing its decline in early hypertensive nephropathy Kidney International (78_ 303-309
bull Mann J Schmieder R E amp McQueen M (2008) Renal outcomes with telmisartan ramipril or both in people at high vascular risk (the ONTARGET study) a multicentre randomised doubleblind ocntrolled trial Lancet 372(9638) 547-533
BIBLIOGRAPHY
bull Matovinović M S (2009) Pathophysiology and classification of kidney disease Retrieved from The Journal of the International Federation of Clinical Chemistry and Laboratory Medicine httpwwwifccorgifccfilesdocs20010902pdf
bull Moe S Drueke T Lameire N amp Eknoyan G (2007 Jan) Chronic kidney disease-mineral-bone disorder a new paradigmdoi101053jackd200610005
bull Murtagh F E Marsh J E Donohoe P Ekbal N J Sheerin N S amp Harris F E (2007 July) Dialysis or not A comparative survival study of patients over 75 years with chronic kidney disease stage 5 Retrieved from Nephrology Dialysis and Transplant 22(7) httpswwwncbinlmnihgovpubmed17412702
bull National Kidney Foundation (2002) KDOQI clinical practice guidelines for chronic kidney disease evaluation classification andstratification American Journal of Kidney Disease S1-S266
bull National Kidney Foundation (2014 November 5) Fact Sheets Retrieved from httpwwwkidneyorgnewsnewsroomfactsheetsFastFacts
bull Pal S (2012 June 2) Trends in chronic kidney disease Retrieved from US Pharmacist (37)6 httpswwwuspharmacistcomarticletrends-in-chronic-kidney-disease
bull Qunibi W amp Henrich W L (2017 Jan 19) Overview of chronic kidney disease-mineral and bone disorder (J Berns amp A M Sheridan Eds) Retrieved from UpToDate httpswww-uptodate-comoverview-of-chronic-kidney-disease-mineral-and-bone-disorder-ckd-mbd
bull Rosenberg M (2016 Feb 24) Overview of the management of chronic kidney disease in adults (G C Curhan amp A M Sheridan Eds) Retrieved from UpToDate UpToDate httpswww-uptodate-comproxywichitaeducontentsoverview-of-the-management-of-chronic-kidney-disease-in-adults
BIBLIOGRAPHY
bull Szczech L Stewart R C Hsu-Lin S DeLosky R J Astor B C Fox C H Vassalotti J A (2014) Primary care detection of chronic kidney disease in adults with type 2 diabetes The ADD-CKD Study (Awareness Detection and Drug Therapy in type 2 diabetes and chronic kidney disease PLOS doihttpsdoiorg101371journalpone0110535
bull USRDS (2016) Annual data report 2016 Epidemiology of kidney disease in the United States Retrieved from United States Renal Data System httpswwwusrdsorgadraspx
bull Vasudev B amp Vasudev M (2012) A model curriculum for residents rotating in nephrology MedEDPORTAL doihttpdoiorg1015766mep_2374-82658288
bull Wei L MacDonald T M Jennings C Sheng X amp Flynn R W (2013) Estimated GFR reporting is associated with decreased nonsteroidal anti-inflammatory drug prescribing and increased renal function Kidney International (84)1 174-178
chronic kidney disease in primary care
CKD as a Public Health Issue
Slide Number 3
Costs of CKD in 2013 dollarsUSRDS report
Steps to CKD Patient Care
Renal anatomy and physiology
Definition of Chronic Kidney Disease
CKD Risk Factors
Gaps in CKD Diagnosis
Slide Number 10
Steps to CKD Patient Care
creatinine
Glomerular filtration rate
Slide Number 14
Slide Number 15
Use These Equations Cautiously if at all in hellip
lab albumin creatinine ratio
The New CKD Categories
Steps to CKD Patient Care
Slide Number 20
Kidney Involvement in Systemic Diseases
Slide Number 22
Slide Number 23
DysmorphicRenal Hematuria
Slide Number 25
If you have albuminuria or hematuria-order the following labs
bull Progression of disease ndash declining eGFR increasing proteinuria
bull Degree of proteinuria nephrotic syndrome gt 05-10 gd on ACEi or ARB therapy
bull Etiology of CKD not certain
bull Need help with disease management
bull Indications for kidney biopsy
Rosenberg 2016
WHEN TO REFER
STEPS TO CKD PATIENT CARE
1 CKD definition and risks2 Assess GFR albuminuria3 Determine etiology4 Assess for evidence of progression5 Assess for associated complications6 Discuss dialysistransplantation
KIDNEY TRANSPLANTATION
bull Treatment of choice for ESRDbull Improves quality of lifebull Waiting list time varies-3-5 yearsbull 3 year survival rate after transplantation is 83-94bull Increased risk of cancer
STARTING DIALYSIS IN THE ELDERLYhellipOR NOT
bull Among patients gt 75 yrs with stage 5 CKD who chose to NOT start dialysisbull Overall more likely to die over next 1-2 years bull But if they had ischemic heart disease or other significant comorbidity NO
DIFFERENCE in survival
bull Active disease management and supportive care may be appropriate without starting dialysis in the ill elderly
bull Palliative care does not mean ldquono carerdquo
bull Must have end-of-life discussions
(Murtagh et al 2007)
CKD MANAGEMENTbull Diagnose cause and treat underlying conditionbull Stage per guidelinesbull Slow progression of kidney disease (ACE inhibitors)bull Monitor for complicationsmdashvolume overload hyperkalemia metabolic acidosis
hyperphosphatemia anorexia fatigue htn bone diseasebull Labs cmp cbc phos Vit D 25OH iPTH urine microscopy uric acid urine
proteincr ratio-frequency based off heat map Get sono at least oncebull Vaccinate influenza hep B pneumococcalbull Eval ASCVD risk-likely needs statinbull Possible dexa (donrsquot give bisphosphonates if GFRlt35 let specialist manage)bull Refer to nephrology when eGFR is lt30 (sometimes if higher risk-refer earlier)
CASE 1
bull 55 year old man with past medical history of headaches presents to your office for his first time visit to a PCP in over 30 years
bull He has no past history of being admitted to the hospital and he does not take any OTC medsNSAIDsherbal meds He has no history of ETOH abuse smoking or drug use
bull Vitals BP 180100 mmHg pulse 80 R 18
bull Exam No JVD S1S2 regular PMI shifted to the left no gallop no abdominal bruit pulses bilaterally equal and regular no leg edema
bull What would you order
bull EKG cbc cmp ua urine proteincr ratio lipid
LAB RESULTS
bull Labs reveal a creatinine of 22 mgdL eGFR 33 Urine shows no blood or casts Urineprotein ratio shows 1 gm protein24 hrs EKG shows LVH
bull Next step in workupbull Renal ultrasound 1st then SPEP UPEP with immunofixation serum free light chains
bull Additional labs neg Renal ultrasound shows that both kidneys are slightly reduced in size and are mildly echogenic with no mass or hydronephrosis
bull What is your diagnosis
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileMain_complications_of_persistent_high_blood_pressurepngCreative Commons License associated httpcreativecommonsorglicensesby-sa30
bull 3 months Howevermdashwe have evidence of structural abnormalities Could potentially stage at G3b A3 (red on the heat map)
bull Goal blood pressure
bull JNC 8 14090 NKF 13080
bull Additional lab needed for progression monitoring
bull Cbc renal panel phos Vit D iPTH uric acid urine micro (we already have the renal sono and urine proteincr ratio and lipid)
Selective renal angiography (left lower renal artery) after successful percutaneous balloon dilatation of the stenotic lesionFibromuscular dysplasia in an accessory renal artery causing renovascular hypertension
Secondary Hypertension
Images retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileRenal_FMD2jpg and httpcommonswikimediaorgwikiFileRenal_FMDjpgCreative Commons License associated httpcreativecommonsorglicensesby20deeden (both images)
CASE 2bull OS is a 64year old Hispanic female in for DM check She has had DM for 15+ years and is currently
taking metformin 1000mg bid Lisinopril 10mg a day atorvastatin 40mg a day Labs today showed the following
bull Hgba1c 86 cmp eGFR 50 lipid WNL proteincr ratio 650mg These results are similar to her last visit
bull Upon further hx-you find that she had a recent eye exam and has mild nonproliferaive retinopathy She does not have neuropathy or other ss
bull What further workup do you need
bull Renal sonogram urine micro iPTH vit D (25 OH) phos uric acid
bull Dx stage
bull G3a A3
bull What further treatment do you need
bull Improve glycemic control Increase Lisinopril to 20mg with a goal of 40mg Avoid NSAIDs or other nephrotoxic agents make sure meds are renally dosed monitor 3xyear nephro referral
MANAGEMENT OF CKD IN DIABETESeGFR Recommended
All patients
Yearly measurement of creatinine urinary albumin excretion potassium
45-60 Referral to a nephrologist if possibility for nondiabetickidney disease existsConsider dose adjustment of medicationsMonitor eGFR every 6 monthsMonitor electrolytes bicarbonate hemoglobin calcium phosphorus parathyroid hormone at least yearly
Assure vitamin D sufficiencyConsider bone density testingReferral for dietary counselling
American Diabetes Association Standards of Medical Care in Diabetes Microvascular complications and foot care Diabetes Care 2017 40 (Suppl 1) S88-S98
CASE 3
bull 19 year old African American woman presents to your clinic with complaints of fatigue joint pains a new rash on her face oral ulcer
bull On exam BP 15080 P 88 Afebrile 96 O2 sats on RAbull GEN No respiratory distress at restbull HEENT painless oral ulcer flat rash over malar eminences sparing the nasolabial fold pallor +bull Lungs CTAbull CVS S1S2 regularbull Abdomen soft NTbull Ext left elbow joint and bilateral wrist joints are swollen and tender
bull What would you orderbull CBC CMP ua urine microscopy (microalbumin or urine proteincr ratio) ANA esr RF anti-ccp uric acid TSH
CASE 3
bull Working dx fatigue oral ulcer joint pain
bull Basic Labs Na 135 K 55 Bicarb 18 BUN 50 Cr 35 eGFR 22 Ca 90 ANA + titer 1640
bull UA 3+ blood 3+ protein RBC casts +
bull Given these results what is the most likely diagnosis
bull What would you do
SYSTEMIC LUPUS ERYTHEMATOSUS (SLE)
bull SLE multisystemic disease Etiology unknown
bull Production of autoantibodies and immune complexes formation
bull There is renal involvement in the great majority of patients with SLE at some time of the evolution 66-90
SLE ndash LUPUS NEPHRITIS
bull Race SLE is more commonsevere in African americans than Caucasiansbull
bull Gender female-to-male ratio of 91
bull Age Most patients develop lupus nephritis early in their disease course SLE is more common among women in the third decade of life and lupus nephritis occurs in patients aged 20-40 years
bull Kidney Biopsy For staging lupus nephritis (Class 1-5)
CASE 5bull A 80 year old man who has not seen a PCP in many years
presents to your clinic for weakness for the past few months On further questioning he tells you that his bones also have been hurting lately and he has developed leg swelling in the past month or so
bull On exam bull BP 16090 P 88 Afebrilebull GEN Thin built manbull HEENT pallor presentbull Lungs clearbull CVS S1S2 regular no rub or gallopbull Abdomen soft NTbull Ext 2 + edema
CASE 5
bull Differentials
bull CHF MI Cancer arthritis
bull Labs
bull CBC CMP urine microscopy urine proteincr ratio ESR TSH EKG BNP pa and lat CXR
bull LABS Urine dipstick negative for protein or blood
bull Basic chem bull Na 136 (135-145) K 51 (35-55) Chloride 108 (96-106) Bicarb 25
Given this presentation and the labs (low anion gap and elevated calcium anemia kidney failure) what will you think of What will you order next
Serum and urine protein electrophoresis
Intratubular refractile casts with surrounding syncytial giant cell reaction with chronic tubulointerstitial nephritis and fibrosis characteristic of myeloma cast nephropathy
Kidney Biopsy
CASE STUDYbull A 35 year old African American woman was seen in the clinic for
chronic cough and dyspnea on exertion She gave history of vague symptoms of fatigue and weight loss of 20 Ibs over the last six months
bull List some differentialsbull TB sarcoid lupus thyroid problems PEbull What would you orderbull PPD cbc cmp UA TSH ANA pa and lat cxr
bull Her labs were significant for mildly elevated calcium level and a creatinine of 20 mgdL eGFR 37
bull She had 750 mg of proteinuriaday
bull PPD neg ANA neg TSH and other labs WNL
bull Assuming this is present more than 3 monthshelliphellipwhat is her ckd stage
bull G3b A3
bull What do we still need
CT scan of chest
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileAnterior_mediastinal_mass_thymomajpgCreative Commons License associated httpcreativecommonsorglicensesby20deeden
CXR ndash HILAR LYMPHADENOPATHY
WHATS NEEDED NEXT
bull Biopsy of hilar lymphadenopathy or renal biopsy
bull DX sarcoidosis
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileSarcoidosis_signs_and_symptomsjpgThis work is in the public domain in the United States because it is a work of the United States Federal Government under the terms of Title 17 Chapter 1 Section 105 of the US Code
NEWLY DX CKD
bull 1) urinalysis microscopy ultrasound proteincr ratio
bull If obstruction-treat
bull No obstruction
bull Hx critical (consider myeloma if high risk)
bull glomerular bleeding or albumin in urine
bull Yes workup for glomerular causes (ANArf hep B C upep spep ANCA complement C3 C4)
bull No sterile pyruria-consider interstitial nephritis
bull High risk renovascular disease Evaluate renovascular disease
Additional Online Resources for CKD LearningbullNational Kidney Foundation wwwkidneyorgbullUnited States Renal Data Service wwwusrdsorgbullCDCrsquos CKD Surveillance Project
httpnccdcdcgovckdbullNational Kidney Disease Education Program
(NKDEP) httpnkdepnihgov
BIBLIOGRAPHY
bull Afzali B amp Goldsmith D J (2016 June 29) Statins and chronic kidney disease (G C Curhan amp A M Sheridan Eds) Retrieved 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsstatins-and-chronic-kidney-disease
bull American Diabetes Association Standards of Medical Care in Diabetes (2017) Microvascular complications and foot care Diabetes Care 2017 (40) S88-S98
bull American Diabetes Association Standards of Medical Care in Diabetes (2017) Microvascular complications and foot care Diabetes Care 40 (suppl 1) S88-S98
bull Berns J S (2017 Mar 22) Treatment of anemia in nondialysis chronic kidney disease (T A Golper amp A M Sheridan Eds) Retrieved from UpToDate httpswww-uptodate-comproxywichitaeducontentstreatment-of-anemia-in-nondialysis-chronic-kidney-disease
bull Chan M Dall A T Fletcher K E Lu N amp Trivedi H (2007) Outcomes in patients with chronic kidney disease referred late to nephrologists a meta-analysis American Journal of Medicine 120(12) 1063-1070
bull Coresh J Selvin E amp Stevens L A (2007) Prevalence of chronic kidny disease in the United States JAMA 298(17) doi101001jama298172038
bull de Brito-Ashurst I Varagunam M Raftery M amp Yagoob M (2009) Bicarbonate supplementation slows progression of CKD and improves nutritional status Journal of American Society of Nephrology (20) 2075-2084
BIBLIOGRAPHY
bull Duncan L Heathcoat J Djurdjev O amp Levin A (2001) Screening for renal disease using serum creatinine who are we missing Nephrology Dialysis and Transplant 16(5) 1042-1046
bull Dunkler D Gao P Lee S F Heinz G Clase C M Tobe S Oberbauer R (2015 August 7) Risk prediction for early CKD in type 2 diabetes Retrieved from Clinical Journal of the American Society of Nephrology httpcjasnasnjournalsorgcontent1081371fullsid=61422554-a5f1-41ac-b696-dcd3b12bd268
bull Fatehi P amp Chi-yuan H (September 15 2016) Diagnostic approach to the patient with newly identified chronic kidney disease (G C Curhan amp A M Sheridan Eds) Retrieved May 7 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsdiagnostic-approach-to-the-patient-with-newly-identified-chronic-kidney-disease
bull Fink J e (2009) Chronic Kidney Disease as an Under-Recognized Threat to Patient Safety American journal of kidney diseases the official journal of the National Kidney Foundation 53(4) 681-688
bull Gaffo A L amp Saag K G (2008 Nov) Management of hyperuricemia and gout in CKD doihttpdxdoiorg101053jajkd200807035
bull Hebert L A amp Parikh S V (2014 June 18) Differential diagnosis and evaluation of glomerular disease (R J Glassock amp A Q Lam Eds) Retrieved May 7 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsdifferential-diagnosis-and-evaluation-of-glomerular-disease
bull Inker L Perrone R D Sterns R H amp Forman J P (2017 March 7) Assessment of kidney function Retrieved from UpToDate httpswww-uptodate-comproxywichitaeducontentsassessment-of-kidney-functionsource=search_resultampsearch=creatinineampselectedTitle=1~150
BIBLIOGRAPHY
bull James P A Ortiz E amp Et Al (2014) Evidence based guideline for the management of high blood pressure in adults (JNC) JAMA 311(5) 507-520
bull Kidney Disease Improving Global Outcomes (KDIGO) CKD Work Group (2013 January) KDIGO 2012 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease Retrieved from Kidney International Supplement httpwwwkidney-internationalorg
bull Kunz R Friedrich C Wolbers M amp Mann J F (2008) Meta-analysis effect of monotherapy and combination therapy with inhibitors of the renin angiotensin system on proteinuria in renal disease Annals of Internal Medicine 148(1) 30-48
bull Levey A Stevens L A Schmid C H Castro A F Feldman H I Kusek J W Coresh J (2009) A new equation to estimate glomerular filtration rate Annals of Internal Medicine 150(9) 604-612
bull Levin A Bakris G L Molitch M Smulders M M Williams L A amp Andress D L (2007 Jan) Prevalence of abnormal serum vitamin D PTH calcium and phosphorus in patients with chronic kidney disease results of the study to evaluate early kidney disease Kidney International 71(1) 31-38 Retrieved from PubMED
bull Mahajan A Simoni J Sheather S Broglio K Rajab M amp Wesson D (2010) Daily oral sodium bicarbonate preserves glomerular filtration rate by slowing its decline in early hypertensive nephropathy Kidney International (78_ 303-309
bull Mann J Schmieder R E amp McQueen M (2008) Renal outcomes with telmisartan ramipril or both in people at high vascular risk (the ONTARGET study) a multicentre randomised doubleblind ocntrolled trial Lancet 372(9638) 547-533
BIBLIOGRAPHY
bull Matovinović M S (2009) Pathophysiology and classification of kidney disease Retrieved from The Journal of the International Federation of Clinical Chemistry and Laboratory Medicine httpwwwifccorgifccfilesdocs20010902pdf
bull Moe S Drueke T Lameire N amp Eknoyan G (2007 Jan) Chronic kidney disease-mineral-bone disorder a new paradigmdoi101053jackd200610005
bull Murtagh F E Marsh J E Donohoe P Ekbal N J Sheerin N S amp Harris F E (2007 July) Dialysis or not A comparative survival study of patients over 75 years with chronic kidney disease stage 5 Retrieved from Nephrology Dialysis and Transplant 22(7) httpswwwncbinlmnihgovpubmed17412702
bull National Kidney Foundation (2002) KDOQI clinical practice guidelines for chronic kidney disease evaluation classification andstratification American Journal of Kidney Disease S1-S266
bull National Kidney Foundation (2014 November 5) Fact Sheets Retrieved from httpwwwkidneyorgnewsnewsroomfactsheetsFastFacts
bull Pal S (2012 June 2) Trends in chronic kidney disease Retrieved from US Pharmacist (37)6 httpswwwuspharmacistcomarticletrends-in-chronic-kidney-disease
bull Qunibi W amp Henrich W L (2017 Jan 19) Overview of chronic kidney disease-mineral and bone disorder (J Berns amp A M Sheridan Eds) Retrieved from UpToDate httpswww-uptodate-comoverview-of-chronic-kidney-disease-mineral-and-bone-disorder-ckd-mbd
bull Rosenberg M (2016 Feb 24) Overview of the management of chronic kidney disease in adults (G C Curhan amp A M Sheridan Eds) Retrieved from UpToDate UpToDate httpswww-uptodate-comproxywichitaeducontentsoverview-of-the-management-of-chronic-kidney-disease-in-adults
BIBLIOGRAPHY
bull Szczech L Stewart R C Hsu-Lin S DeLosky R J Astor B C Fox C H Vassalotti J A (2014) Primary care detection of chronic kidney disease in adults with type 2 diabetes The ADD-CKD Study (Awareness Detection and Drug Therapy in type 2 diabetes and chronic kidney disease PLOS doihttpsdoiorg101371journalpone0110535
bull USRDS (2016) Annual data report 2016 Epidemiology of kidney disease in the United States Retrieved from United States Renal Data System httpswwwusrdsorgadraspx
bull Vasudev B amp Vasudev M (2012) A model curriculum for residents rotating in nephrology MedEDPORTAL doihttpdoiorg1015766mep_2374-82658288
bull Wei L MacDonald T M Jennings C Sheng X amp Flynn R W (2013) Estimated GFR reporting is associated with decreased nonsteroidal anti-inflammatory drug prescribing and increased renal function Kidney International (84)1 174-178
chronic kidney disease in primary care
CKD as a Public Health Issue
Slide Number 3
Costs of CKD in 2013 dollarsUSRDS report
Steps to CKD Patient Care
Renal anatomy and physiology
Definition of Chronic Kidney Disease
CKD Risk Factors
Gaps in CKD Diagnosis
Slide Number 10
Steps to CKD Patient Care
creatinine
Glomerular filtration rate
Slide Number 14
Slide Number 15
Use These Equations Cautiously if at all in hellip
lab albumin creatinine ratio
The New CKD Categories
Steps to CKD Patient Care
Slide Number 20
Kidney Involvement in Systemic Diseases
Slide Number 22
Slide Number 23
DysmorphicRenal Hematuria
Slide Number 25
If you have albuminuria or hematuria-order the following labs
bull Progression of disease ndash declining eGFR increasing proteinuria
bull Degree of proteinuria nephrotic syndrome gt 05-10 gd on ACEi or ARB therapy
bull Etiology of CKD not certain
bull Need help with disease management
bull Indications for kidney biopsy
Rosenberg 2016
WHEN TO REFER
STEPS TO CKD PATIENT CARE
1 CKD definition and risks2 Assess GFR albuminuria3 Determine etiology4 Assess for evidence of progression5 Assess for associated complications6 Discuss dialysistransplantation
KIDNEY TRANSPLANTATION
bull Treatment of choice for ESRDbull Improves quality of lifebull Waiting list time varies-3-5 yearsbull 3 year survival rate after transplantation is 83-94bull Increased risk of cancer
STARTING DIALYSIS IN THE ELDERLYhellipOR NOT
bull Among patients gt 75 yrs with stage 5 CKD who chose to NOT start dialysisbull Overall more likely to die over next 1-2 years bull But if they had ischemic heart disease or other significant comorbidity NO
DIFFERENCE in survival
bull Active disease management and supportive care may be appropriate without starting dialysis in the ill elderly
bull Palliative care does not mean ldquono carerdquo
bull Must have end-of-life discussions
(Murtagh et al 2007)
CKD MANAGEMENTbull Diagnose cause and treat underlying conditionbull Stage per guidelinesbull Slow progression of kidney disease (ACE inhibitors)bull Monitor for complicationsmdashvolume overload hyperkalemia metabolic acidosis
hyperphosphatemia anorexia fatigue htn bone diseasebull Labs cmp cbc phos Vit D 25OH iPTH urine microscopy uric acid urine
proteincr ratio-frequency based off heat map Get sono at least oncebull Vaccinate influenza hep B pneumococcalbull Eval ASCVD risk-likely needs statinbull Possible dexa (donrsquot give bisphosphonates if GFRlt35 let specialist manage)bull Refer to nephrology when eGFR is lt30 (sometimes if higher risk-refer earlier)
CASE 1
bull 55 year old man with past medical history of headaches presents to your office for his first time visit to a PCP in over 30 years
bull He has no past history of being admitted to the hospital and he does not take any OTC medsNSAIDsherbal meds He has no history of ETOH abuse smoking or drug use
bull Vitals BP 180100 mmHg pulse 80 R 18
bull Exam No JVD S1S2 regular PMI shifted to the left no gallop no abdominal bruit pulses bilaterally equal and regular no leg edema
bull What would you order
bull EKG cbc cmp ua urine proteincr ratio lipid
LAB RESULTS
bull Labs reveal a creatinine of 22 mgdL eGFR 33 Urine shows no blood or casts Urineprotein ratio shows 1 gm protein24 hrs EKG shows LVH
bull Next step in workupbull Renal ultrasound 1st then SPEP UPEP with immunofixation serum free light chains
bull Additional labs neg Renal ultrasound shows that both kidneys are slightly reduced in size and are mildly echogenic with no mass or hydronephrosis
bull What is your diagnosis
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileMain_complications_of_persistent_high_blood_pressurepngCreative Commons License associated httpcreativecommonsorglicensesby-sa30
bull 3 months Howevermdashwe have evidence of structural abnormalities Could potentially stage at G3b A3 (red on the heat map)
bull Goal blood pressure
bull JNC 8 14090 NKF 13080
bull Additional lab needed for progression monitoring
bull Cbc renal panel phos Vit D iPTH uric acid urine micro (we already have the renal sono and urine proteincr ratio and lipid)
Selective renal angiography (left lower renal artery) after successful percutaneous balloon dilatation of the stenotic lesionFibromuscular dysplasia in an accessory renal artery causing renovascular hypertension
Secondary Hypertension
Images retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileRenal_FMD2jpg and httpcommonswikimediaorgwikiFileRenal_FMDjpgCreative Commons License associated httpcreativecommonsorglicensesby20deeden (both images)
CASE 2bull OS is a 64year old Hispanic female in for DM check She has had DM for 15+ years and is currently
taking metformin 1000mg bid Lisinopril 10mg a day atorvastatin 40mg a day Labs today showed the following
bull Hgba1c 86 cmp eGFR 50 lipid WNL proteincr ratio 650mg These results are similar to her last visit
bull Upon further hx-you find that she had a recent eye exam and has mild nonproliferaive retinopathy She does not have neuropathy or other ss
bull What further workup do you need
bull Renal sonogram urine micro iPTH vit D (25 OH) phos uric acid
bull Dx stage
bull G3a A3
bull What further treatment do you need
bull Improve glycemic control Increase Lisinopril to 20mg with a goal of 40mg Avoid NSAIDs or other nephrotoxic agents make sure meds are renally dosed monitor 3xyear nephro referral
MANAGEMENT OF CKD IN DIABETESeGFR Recommended
All patients
Yearly measurement of creatinine urinary albumin excretion potassium
45-60 Referral to a nephrologist if possibility for nondiabetickidney disease existsConsider dose adjustment of medicationsMonitor eGFR every 6 monthsMonitor electrolytes bicarbonate hemoglobin calcium phosphorus parathyroid hormone at least yearly
Assure vitamin D sufficiencyConsider bone density testingReferral for dietary counselling
American Diabetes Association Standards of Medical Care in Diabetes Microvascular complications and foot care Diabetes Care 2017 40 (Suppl 1) S88-S98
CASE 3
bull 19 year old African American woman presents to your clinic with complaints of fatigue joint pains a new rash on her face oral ulcer
bull On exam BP 15080 P 88 Afebrile 96 O2 sats on RAbull GEN No respiratory distress at restbull HEENT painless oral ulcer flat rash over malar eminences sparing the nasolabial fold pallor +bull Lungs CTAbull CVS S1S2 regularbull Abdomen soft NTbull Ext left elbow joint and bilateral wrist joints are swollen and tender
bull What would you orderbull CBC CMP ua urine microscopy (microalbumin or urine proteincr ratio) ANA esr RF anti-ccp uric acid TSH
CASE 3
bull Working dx fatigue oral ulcer joint pain
bull Basic Labs Na 135 K 55 Bicarb 18 BUN 50 Cr 35 eGFR 22 Ca 90 ANA + titer 1640
bull UA 3+ blood 3+ protein RBC casts +
bull Given these results what is the most likely diagnosis
bull What would you do
SYSTEMIC LUPUS ERYTHEMATOSUS (SLE)
bull SLE multisystemic disease Etiology unknown
bull Production of autoantibodies and immune complexes formation
bull There is renal involvement in the great majority of patients with SLE at some time of the evolution 66-90
SLE ndash LUPUS NEPHRITIS
bull Race SLE is more commonsevere in African americans than Caucasiansbull
bull Gender female-to-male ratio of 91
bull Age Most patients develop lupus nephritis early in their disease course SLE is more common among women in the third decade of life and lupus nephritis occurs in patients aged 20-40 years
bull Kidney Biopsy For staging lupus nephritis (Class 1-5)
CASE 5bull A 80 year old man who has not seen a PCP in many years
presents to your clinic for weakness for the past few months On further questioning he tells you that his bones also have been hurting lately and he has developed leg swelling in the past month or so
bull On exam bull BP 16090 P 88 Afebrilebull GEN Thin built manbull HEENT pallor presentbull Lungs clearbull CVS S1S2 regular no rub or gallopbull Abdomen soft NTbull Ext 2 + edema
CASE 5
bull Differentials
bull CHF MI Cancer arthritis
bull Labs
bull CBC CMP urine microscopy urine proteincr ratio ESR TSH EKG BNP pa and lat CXR
bull LABS Urine dipstick negative for protein or blood
bull Basic chem bull Na 136 (135-145) K 51 (35-55) Chloride 108 (96-106) Bicarb 25
Given this presentation and the labs (low anion gap and elevated calcium anemia kidney failure) what will you think of What will you order next
Serum and urine protein electrophoresis
Intratubular refractile casts with surrounding syncytial giant cell reaction with chronic tubulointerstitial nephritis and fibrosis characteristic of myeloma cast nephropathy
Kidney Biopsy
CASE STUDYbull A 35 year old African American woman was seen in the clinic for
chronic cough and dyspnea on exertion She gave history of vague symptoms of fatigue and weight loss of 20 Ibs over the last six months
bull List some differentialsbull TB sarcoid lupus thyroid problems PEbull What would you orderbull PPD cbc cmp UA TSH ANA pa and lat cxr
bull Her labs were significant for mildly elevated calcium level and a creatinine of 20 mgdL eGFR 37
bull She had 750 mg of proteinuriaday
bull PPD neg ANA neg TSH and other labs WNL
bull Assuming this is present more than 3 monthshelliphellipwhat is her ckd stage
bull G3b A3
bull What do we still need
CT scan of chest
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileAnterior_mediastinal_mass_thymomajpgCreative Commons License associated httpcreativecommonsorglicensesby20deeden
CXR ndash HILAR LYMPHADENOPATHY
WHATS NEEDED NEXT
bull Biopsy of hilar lymphadenopathy or renal biopsy
bull DX sarcoidosis
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileSarcoidosis_signs_and_symptomsjpgThis work is in the public domain in the United States because it is a work of the United States Federal Government under the terms of Title 17 Chapter 1 Section 105 of the US Code
NEWLY DX CKD
bull 1) urinalysis microscopy ultrasound proteincr ratio
bull If obstruction-treat
bull No obstruction
bull Hx critical (consider myeloma if high risk)
bull glomerular bleeding or albumin in urine
bull Yes workup for glomerular causes (ANArf hep B C upep spep ANCA complement C3 C4)
bull No sterile pyruria-consider interstitial nephritis
bull High risk renovascular disease Evaluate renovascular disease
Additional Online Resources for CKD LearningbullNational Kidney Foundation wwwkidneyorgbullUnited States Renal Data Service wwwusrdsorgbullCDCrsquos CKD Surveillance Project
httpnccdcdcgovckdbullNational Kidney Disease Education Program
(NKDEP) httpnkdepnihgov
BIBLIOGRAPHY
bull Afzali B amp Goldsmith D J (2016 June 29) Statins and chronic kidney disease (G C Curhan amp A M Sheridan Eds) Retrieved 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsstatins-and-chronic-kidney-disease
bull American Diabetes Association Standards of Medical Care in Diabetes (2017) Microvascular complications and foot care Diabetes Care 2017 (40) S88-S98
bull American Diabetes Association Standards of Medical Care in Diabetes (2017) Microvascular complications and foot care Diabetes Care 40 (suppl 1) S88-S98
bull Berns J S (2017 Mar 22) Treatment of anemia in nondialysis chronic kidney disease (T A Golper amp A M Sheridan Eds) Retrieved from UpToDate httpswww-uptodate-comproxywichitaeducontentstreatment-of-anemia-in-nondialysis-chronic-kidney-disease
bull Chan M Dall A T Fletcher K E Lu N amp Trivedi H (2007) Outcomes in patients with chronic kidney disease referred late to nephrologists a meta-analysis American Journal of Medicine 120(12) 1063-1070
bull Coresh J Selvin E amp Stevens L A (2007) Prevalence of chronic kidny disease in the United States JAMA 298(17) doi101001jama298172038
bull de Brito-Ashurst I Varagunam M Raftery M amp Yagoob M (2009) Bicarbonate supplementation slows progression of CKD and improves nutritional status Journal of American Society of Nephrology (20) 2075-2084
BIBLIOGRAPHY
bull Duncan L Heathcoat J Djurdjev O amp Levin A (2001) Screening for renal disease using serum creatinine who are we missing Nephrology Dialysis and Transplant 16(5) 1042-1046
bull Dunkler D Gao P Lee S F Heinz G Clase C M Tobe S Oberbauer R (2015 August 7) Risk prediction for early CKD in type 2 diabetes Retrieved from Clinical Journal of the American Society of Nephrology httpcjasnasnjournalsorgcontent1081371fullsid=61422554-a5f1-41ac-b696-dcd3b12bd268
bull Fatehi P amp Chi-yuan H (September 15 2016) Diagnostic approach to the patient with newly identified chronic kidney disease (G C Curhan amp A M Sheridan Eds) Retrieved May 7 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsdiagnostic-approach-to-the-patient-with-newly-identified-chronic-kidney-disease
bull Fink J e (2009) Chronic Kidney Disease as an Under-Recognized Threat to Patient Safety American journal of kidney diseases the official journal of the National Kidney Foundation 53(4) 681-688
bull Gaffo A L amp Saag K G (2008 Nov) Management of hyperuricemia and gout in CKD doihttpdxdoiorg101053jajkd200807035
bull Hebert L A amp Parikh S V (2014 June 18) Differential diagnosis and evaluation of glomerular disease (R J Glassock amp A Q Lam Eds) Retrieved May 7 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsdifferential-diagnosis-and-evaluation-of-glomerular-disease
bull Inker L Perrone R D Sterns R H amp Forman J P (2017 March 7) Assessment of kidney function Retrieved from UpToDate httpswww-uptodate-comproxywichitaeducontentsassessment-of-kidney-functionsource=search_resultampsearch=creatinineampselectedTitle=1~150
BIBLIOGRAPHY
bull James P A Ortiz E amp Et Al (2014) Evidence based guideline for the management of high blood pressure in adults (JNC) JAMA 311(5) 507-520
bull Kidney Disease Improving Global Outcomes (KDIGO) CKD Work Group (2013 January) KDIGO 2012 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease Retrieved from Kidney International Supplement httpwwwkidney-internationalorg
bull Kunz R Friedrich C Wolbers M amp Mann J F (2008) Meta-analysis effect of monotherapy and combination therapy with inhibitors of the renin angiotensin system on proteinuria in renal disease Annals of Internal Medicine 148(1) 30-48
bull Levey A Stevens L A Schmid C H Castro A F Feldman H I Kusek J W Coresh J (2009) A new equation to estimate glomerular filtration rate Annals of Internal Medicine 150(9) 604-612
bull Levin A Bakris G L Molitch M Smulders M M Williams L A amp Andress D L (2007 Jan) Prevalence of abnormal serum vitamin D PTH calcium and phosphorus in patients with chronic kidney disease results of the study to evaluate early kidney disease Kidney International 71(1) 31-38 Retrieved from PubMED
bull Mahajan A Simoni J Sheather S Broglio K Rajab M amp Wesson D (2010) Daily oral sodium bicarbonate preserves glomerular filtration rate by slowing its decline in early hypertensive nephropathy Kidney International (78_ 303-309
bull Mann J Schmieder R E amp McQueen M (2008) Renal outcomes with telmisartan ramipril or both in people at high vascular risk (the ONTARGET study) a multicentre randomised doubleblind ocntrolled trial Lancet 372(9638) 547-533
BIBLIOGRAPHY
bull Matovinović M S (2009) Pathophysiology and classification of kidney disease Retrieved from The Journal of the International Federation of Clinical Chemistry and Laboratory Medicine httpwwwifccorgifccfilesdocs20010902pdf
bull Moe S Drueke T Lameire N amp Eknoyan G (2007 Jan) Chronic kidney disease-mineral-bone disorder a new paradigmdoi101053jackd200610005
bull Murtagh F E Marsh J E Donohoe P Ekbal N J Sheerin N S amp Harris F E (2007 July) Dialysis or not A comparative survival study of patients over 75 years with chronic kidney disease stage 5 Retrieved from Nephrology Dialysis and Transplant 22(7) httpswwwncbinlmnihgovpubmed17412702
bull National Kidney Foundation (2002) KDOQI clinical practice guidelines for chronic kidney disease evaluation classification andstratification American Journal of Kidney Disease S1-S266
bull National Kidney Foundation (2014 November 5) Fact Sheets Retrieved from httpwwwkidneyorgnewsnewsroomfactsheetsFastFacts
bull Pal S (2012 June 2) Trends in chronic kidney disease Retrieved from US Pharmacist (37)6 httpswwwuspharmacistcomarticletrends-in-chronic-kidney-disease
bull Qunibi W amp Henrich W L (2017 Jan 19) Overview of chronic kidney disease-mineral and bone disorder (J Berns amp A M Sheridan Eds) Retrieved from UpToDate httpswww-uptodate-comoverview-of-chronic-kidney-disease-mineral-and-bone-disorder-ckd-mbd
bull Rosenberg M (2016 Feb 24) Overview of the management of chronic kidney disease in adults (G C Curhan amp A M Sheridan Eds) Retrieved from UpToDate UpToDate httpswww-uptodate-comproxywichitaeducontentsoverview-of-the-management-of-chronic-kidney-disease-in-adults
BIBLIOGRAPHY
bull Szczech L Stewart R C Hsu-Lin S DeLosky R J Astor B C Fox C H Vassalotti J A (2014) Primary care detection of chronic kidney disease in adults with type 2 diabetes The ADD-CKD Study (Awareness Detection and Drug Therapy in type 2 diabetes and chronic kidney disease PLOS doihttpsdoiorg101371journalpone0110535
bull USRDS (2016) Annual data report 2016 Epidemiology of kidney disease in the United States Retrieved from United States Renal Data System httpswwwusrdsorgadraspx
bull Vasudev B amp Vasudev M (2012) A model curriculum for residents rotating in nephrology MedEDPORTAL doihttpdoiorg1015766mep_2374-82658288
bull Wei L MacDonald T M Jennings C Sheng X amp Flynn R W (2013) Estimated GFR reporting is associated with decreased nonsteroidal anti-inflammatory drug prescribing and increased renal function Kidney International (84)1 174-178
chronic kidney disease in primary care
CKD as a Public Health Issue
Slide Number 3
Costs of CKD in 2013 dollarsUSRDS report
Steps to CKD Patient Care
Renal anatomy and physiology
Definition of Chronic Kidney Disease
CKD Risk Factors
Gaps in CKD Diagnosis
Slide Number 10
Steps to CKD Patient Care
creatinine
Glomerular filtration rate
Slide Number 14
Slide Number 15
Use These Equations Cautiously if at all in hellip
lab albumin creatinine ratio
The New CKD Categories
Steps to CKD Patient Care
Slide Number 20
Kidney Involvement in Systemic Diseases
Slide Number 22
Slide Number 23
DysmorphicRenal Hematuria
Slide Number 25
If you have albuminuria or hematuria-order the following labs
bull Progression of disease ndash declining eGFR increasing proteinuria
bull Degree of proteinuria nephrotic syndrome gt 05-10 gd on ACEi or ARB therapy
bull Etiology of CKD not certain
bull Need help with disease management
bull Indications for kidney biopsy
Rosenberg 2016
WHEN TO REFER
STEPS TO CKD PATIENT CARE
1 CKD definition and risks2 Assess GFR albuminuria3 Determine etiology4 Assess for evidence of progression5 Assess for associated complications6 Discuss dialysistransplantation
KIDNEY TRANSPLANTATION
bull Treatment of choice for ESRDbull Improves quality of lifebull Waiting list time varies-3-5 yearsbull 3 year survival rate after transplantation is 83-94bull Increased risk of cancer
STARTING DIALYSIS IN THE ELDERLYhellipOR NOT
bull Among patients gt 75 yrs with stage 5 CKD who chose to NOT start dialysisbull Overall more likely to die over next 1-2 years bull But if they had ischemic heart disease or other significant comorbidity NO
DIFFERENCE in survival
bull Active disease management and supportive care may be appropriate without starting dialysis in the ill elderly
bull Palliative care does not mean ldquono carerdquo
bull Must have end-of-life discussions
(Murtagh et al 2007)
CKD MANAGEMENTbull Diagnose cause and treat underlying conditionbull Stage per guidelinesbull Slow progression of kidney disease (ACE inhibitors)bull Monitor for complicationsmdashvolume overload hyperkalemia metabolic acidosis
hyperphosphatemia anorexia fatigue htn bone diseasebull Labs cmp cbc phos Vit D 25OH iPTH urine microscopy uric acid urine
proteincr ratio-frequency based off heat map Get sono at least oncebull Vaccinate influenza hep B pneumococcalbull Eval ASCVD risk-likely needs statinbull Possible dexa (donrsquot give bisphosphonates if GFRlt35 let specialist manage)bull Refer to nephrology when eGFR is lt30 (sometimes if higher risk-refer earlier)
CASE 1
bull 55 year old man with past medical history of headaches presents to your office for his first time visit to a PCP in over 30 years
bull He has no past history of being admitted to the hospital and he does not take any OTC medsNSAIDsherbal meds He has no history of ETOH abuse smoking or drug use
bull Vitals BP 180100 mmHg pulse 80 R 18
bull Exam No JVD S1S2 regular PMI shifted to the left no gallop no abdominal bruit pulses bilaterally equal and regular no leg edema
bull What would you order
bull EKG cbc cmp ua urine proteincr ratio lipid
LAB RESULTS
bull Labs reveal a creatinine of 22 mgdL eGFR 33 Urine shows no blood or casts Urineprotein ratio shows 1 gm protein24 hrs EKG shows LVH
bull Next step in workupbull Renal ultrasound 1st then SPEP UPEP with immunofixation serum free light chains
bull Additional labs neg Renal ultrasound shows that both kidneys are slightly reduced in size and are mildly echogenic with no mass or hydronephrosis
bull What is your diagnosis
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileMain_complications_of_persistent_high_blood_pressurepngCreative Commons License associated httpcreativecommonsorglicensesby-sa30
bull 3 months Howevermdashwe have evidence of structural abnormalities Could potentially stage at G3b A3 (red on the heat map)
bull Goal blood pressure
bull JNC 8 14090 NKF 13080
bull Additional lab needed for progression monitoring
bull Cbc renal panel phos Vit D iPTH uric acid urine micro (we already have the renal sono and urine proteincr ratio and lipid)
Selective renal angiography (left lower renal artery) after successful percutaneous balloon dilatation of the stenotic lesionFibromuscular dysplasia in an accessory renal artery causing renovascular hypertension
Secondary Hypertension
Images retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileRenal_FMD2jpg and httpcommonswikimediaorgwikiFileRenal_FMDjpgCreative Commons License associated httpcreativecommonsorglicensesby20deeden (both images)
CASE 2bull OS is a 64year old Hispanic female in for DM check She has had DM for 15+ years and is currently
taking metformin 1000mg bid Lisinopril 10mg a day atorvastatin 40mg a day Labs today showed the following
bull Hgba1c 86 cmp eGFR 50 lipid WNL proteincr ratio 650mg These results are similar to her last visit
bull Upon further hx-you find that she had a recent eye exam and has mild nonproliferaive retinopathy She does not have neuropathy or other ss
bull What further workup do you need
bull Renal sonogram urine micro iPTH vit D (25 OH) phos uric acid
bull Dx stage
bull G3a A3
bull What further treatment do you need
bull Improve glycemic control Increase Lisinopril to 20mg with a goal of 40mg Avoid NSAIDs or other nephrotoxic agents make sure meds are renally dosed monitor 3xyear nephro referral
MANAGEMENT OF CKD IN DIABETESeGFR Recommended
All patients
Yearly measurement of creatinine urinary albumin excretion potassium
45-60 Referral to a nephrologist if possibility for nondiabetickidney disease existsConsider dose adjustment of medicationsMonitor eGFR every 6 monthsMonitor electrolytes bicarbonate hemoglobin calcium phosphorus parathyroid hormone at least yearly
Assure vitamin D sufficiencyConsider bone density testingReferral for dietary counselling
American Diabetes Association Standards of Medical Care in Diabetes Microvascular complications and foot care Diabetes Care 2017 40 (Suppl 1) S88-S98
CASE 3
bull 19 year old African American woman presents to your clinic with complaints of fatigue joint pains a new rash on her face oral ulcer
bull On exam BP 15080 P 88 Afebrile 96 O2 sats on RAbull GEN No respiratory distress at restbull HEENT painless oral ulcer flat rash over malar eminences sparing the nasolabial fold pallor +bull Lungs CTAbull CVS S1S2 regularbull Abdomen soft NTbull Ext left elbow joint and bilateral wrist joints are swollen and tender
bull What would you orderbull CBC CMP ua urine microscopy (microalbumin or urine proteincr ratio) ANA esr RF anti-ccp uric acid TSH
CASE 3
bull Working dx fatigue oral ulcer joint pain
bull Basic Labs Na 135 K 55 Bicarb 18 BUN 50 Cr 35 eGFR 22 Ca 90 ANA + titer 1640
bull UA 3+ blood 3+ protein RBC casts +
bull Given these results what is the most likely diagnosis
bull What would you do
SYSTEMIC LUPUS ERYTHEMATOSUS (SLE)
bull SLE multisystemic disease Etiology unknown
bull Production of autoantibodies and immune complexes formation
bull There is renal involvement in the great majority of patients with SLE at some time of the evolution 66-90
SLE ndash LUPUS NEPHRITIS
bull Race SLE is more commonsevere in African americans than Caucasiansbull
bull Gender female-to-male ratio of 91
bull Age Most patients develop lupus nephritis early in their disease course SLE is more common among women in the third decade of life and lupus nephritis occurs in patients aged 20-40 years
bull Kidney Biopsy For staging lupus nephritis (Class 1-5)
CASE 5bull A 80 year old man who has not seen a PCP in many years
presents to your clinic for weakness for the past few months On further questioning he tells you that his bones also have been hurting lately and he has developed leg swelling in the past month or so
bull On exam bull BP 16090 P 88 Afebrilebull GEN Thin built manbull HEENT pallor presentbull Lungs clearbull CVS S1S2 regular no rub or gallopbull Abdomen soft NTbull Ext 2 + edema
CASE 5
bull Differentials
bull CHF MI Cancer arthritis
bull Labs
bull CBC CMP urine microscopy urine proteincr ratio ESR TSH EKG BNP pa and lat CXR
bull LABS Urine dipstick negative for protein or blood
bull Basic chem bull Na 136 (135-145) K 51 (35-55) Chloride 108 (96-106) Bicarb 25
Given this presentation and the labs (low anion gap and elevated calcium anemia kidney failure) what will you think of What will you order next
Serum and urine protein electrophoresis
Intratubular refractile casts with surrounding syncytial giant cell reaction with chronic tubulointerstitial nephritis and fibrosis characteristic of myeloma cast nephropathy
Kidney Biopsy
CASE STUDYbull A 35 year old African American woman was seen in the clinic for
chronic cough and dyspnea on exertion She gave history of vague symptoms of fatigue and weight loss of 20 Ibs over the last six months
bull List some differentialsbull TB sarcoid lupus thyroid problems PEbull What would you orderbull PPD cbc cmp UA TSH ANA pa and lat cxr
bull Her labs were significant for mildly elevated calcium level and a creatinine of 20 mgdL eGFR 37
bull She had 750 mg of proteinuriaday
bull PPD neg ANA neg TSH and other labs WNL
bull Assuming this is present more than 3 monthshelliphellipwhat is her ckd stage
bull G3b A3
bull What do we still need
CT scan of chest
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileAnterior_mediastinal_mass_thymomajpgCreative Commons License associated httpcreativecommonsorglicensesby20deeden
CXR ndash HILAR LYMPHADENOPATHY
WHATS NEEDED NEXT
bull Biopsy of hilar lymphadenopathy or renal biopsy
bull DX sarcoidosis
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileSarcoidosis_signs_and_symptomsjpgThis work is in the public domain in the United States because it is a work of the United States Federal Government under the terms of Title 17 Chapter 1 Section 105 of the US Code
NEWLY DX CKD
bull 1) urinalysis microscopy ultrasound proteincr ratio
bull If obstruction-treat
bull No obstruction
bull Hx critical (consider myeloma if high risk)
bull glomerular bleeding or albumin in urine
bull Yes workup for glomerular causes (ANArf hep B C upep spep ANCA complement C3 C4)
bull No sterile pyruria-consider interstitial nephritis
bull High risk renovascular disease Evaluate renovascular disease
Additional Online Resources for CKD LearningbullNational Kidney Foundation wwwkidneyorgbullUnited States Renal Data Service wwwusrdsorgbullCDCrsquos CKD Surveillance Project
httpnccdcdcgovckdbullNational Kidney Disease Education Program
(NKDEP) httpnkdepnihgov
BIBLIOGRAPHY
bull Afzali B amp Goldsmith D J (2016 June 29) Statins and chronic kidney disease (G C Curhan amp A M Sheridan Eds) Retrieved 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsstatins-and-chronic-kidney-disease
bull American Diabetes Association Standards of Medical Care in Diabetes (2017) Microvascular complications and foot care Diabetes Care 2017 (40) S88-S98
bull American Diabetes Association Standards of Medical Care in Diabetes (2017) Microvascular complications and foot care Diabetes Care 40 (suppl 1) S88-S98
bull Berns J S (2017 Mar 22) Treatment of anemia in nondialysis chronic kidney disease (T A Golper amp A M Sheridan Eds) Retrieved from UpToDate httpswww-uptodate-comproxywichitaeducontentstreatment-of-anemia-in-nondialysis-chronic-kidney-disease
bull Chan M Dall A T Fletcher K E Lu N amp Trivedi H (2007) Outcomes in patients with chronic kidney disease referred late to nephrologists a meta-analysis American Journal of Medicine 120(12) 1063-1070
bull Coresh J Selvin E amp Stevens L A (2007) Prevalence of chronic kidny disease in the United States JAMA 298(17) doi101001jama298172038
bull de Brito-Ashurst I Varagunam M Raftery M amp Yagoob M (2009) Bicarbonate supplementation slows progression of CKD and improves nutritional status Journal of American Society of Nephrology (20) 2075-2084
BIBLIOGRAPHY
bull Duncan L Heathcoat J Djurdjev O amp Levin A (2001) Screening for renal disease using serum creatinine who are we missing Nephrology Dialysis and Transplant 16(5) 1042-1046
bull Dunkler D Gao P Lee S F Heinz G Clase C M Tobe S Oberbauer R (2015 August 7) Risk prediction for early CKD in type 2 diabetes Retrieved from Clinical Journal of the American Society of Nephrology httpcjasnasnjournalsorgcontent1081371fullsid=61422554-a5f1-41ac-b696-dcd3b12bd268
bull Fatehi P amp Chi-yuan H (September 15 2016) Diagnostic approach to the patient with newly identified chronic kidney disease (G C Curhan amp A M Sheridan Eds) Retrieved May 7 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsdiagnostic-approach-to-the-patient-with-newly-identified-chronic-kidney-disease
bull Fink J e (2009) Chronic Kidney Disease as an Under-Recognized Threat to Patient Safety American journal of kidney diseases the official journal of the National Kidney Foundation 53(4) 681-688
bull Gaffo A L amp Saag K G (2008 Nov) Management of hyperuricemia and gout in CKD doihttpdxdoiorg101053jajkd200807035
bull Hebert L A amp Parikh S V (2014 June 18) Differential diagnosis and evaluation of glomerular disease (R J Glassock amp A Q Lam Eds) Retrieved May 7 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsdifferential-diagnosis-and-evaluation-of-glomerular-disease
bull Inker L Perrone R D Sterns R H amp Forman J P (2017 March 7) Assessment of kidney function Retrieved from UpToDate httpswww-uptodate-comproxywichitaeducontentsassessment-of-kidney-functionsource=search_resultampsearch=creatinineampselectedTitle=1~150
BIBLIOGRAPHY
bull James P A Ortiz E amp Et Al (2014) Evidence based guideline for the management of high blood pressure in adults (JNC) JAMA 311(5) 507-520
bull Kidney Disease Improving Global Outcomes (KDIGO) CKD Work Group (2013 January) KDIGO 2012 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease Retrieved from Kidney International Supplement httpwwwkidney-internationalorg
bull Kunz R Friedrich C Wolbers M amp Mann J F (2008) Meta-analysis effect of monotherapy and combination therapy with inhibitors of the renin angiotensin system on proteinuria in renal disease Annals of Internal Medicine 148(1) 30-48
bull Levey A Stevens L A Schmid C H Castro A F Feldman H I Kusek J W Coresh J (2009) A new equation to estimate glomerular filtration rate Annals of Internal Medicine 150(9) 604-612
bull Levin A Bakris G L Molitch M Smulders M M Williams L A amp Andress D L (2007 Jan) Prevalence of abnormal serum vitamin D PTH calcium and phosphorus in patients with chronic kidney disease results of the study to evaluate early kidney disease Kidney International 71(1) 31-38 Retrieved from PubMED
bull Mahajan A Simoni J Sheather S Broglio K Rajab M amp Wesson D (2010) Daily oral sodium bicarbonate preserves glomerular filtration rate by slowing its decline in early hypertensive nephropathy Kidney International (78_ 303-309
bull Mann J Schmieder R E amp McQueen M (2008) Renal outcomes with telmisartan ramipril or both in people at high vascular risk (the ONTARGET study) a multicentre randomised doubleblind ocntrolled trial Lancet 372(9638) 547-533
BIBLIOGRAPHY
bull Matovinović M S (2009) Pathophysiology and classification of kidney disease Retrieved from The Journal of the International Federation of Clinical Chemistry and Laboratory Medicine httpwwwifccorgifccfilesdocs20010902pdf
bull Moe S Drueke T Lameire N amp Eknoyan G (2007 Jan) Chronic kidney disease-mineral-bone disorder a new paradigmdoi101053jackd200610005
bull Murtagh F E Marsh J E Donohoe P Ekbal N J Sheerin N S amp Harris F E (2007 July) Dialysis or not A comparative survival study of patients over 75 years with chronic kidney disease stage 5 Retrieved from Nephrology Dialysis and Transplant 22(7) httpswwwncbinlmnihgovpubmed17412702
bull National Kidney Foundation (2002) KDOQI clinical practice guidelines for chronic kidney disease evaluation classification andstratification American Journal of Kidney Disease S1-S266
bull National Kidney Foundation (2014 November 5) Fact Sheets Retrieved from httpwwwkidneyorgnewsnewsroomfactsheetsFastFacts
bull Pal S (2012 June 2) Trends in chronic kidney disease Retrieved from US Pharmacist (37)6 httpswwwuspharmacistcomarticletrends-in-chronic-kidney-disease
bull Qunibi W amp Henrich W L (2017 Jan 19) Overview of chronic kidney disease-mineral and bone disorder (J Berns amp A M Sheridan Eds) Retrieved from UpToDate httpswww-uptodate-comoverview-of-chronic-kidney-disease-mineral-and-bone-disorder-ckd-mbd
bull Rosenberg M (2016 Feb 24) Overview of the management of chronic kidney disease in adults (G C Curhan amp A M Sheridan Eds) Retrieved from UpToDate UpToDate httpswww-uptodate-comproxywichitaeducontentsoverview-of-the-management-of-chronic-kidney-disease-in-adults
BIBLIOGRAPHY
bull Szczech L Stewart R C Hsu-Lin S DeLosky R J Astor B C Fox C H Vassalotti J A (2014) Primary care detection of chronic kidney disease in adults with type 2 diabetes The ADD-CKD Study (Awareness Detection and Drug Therapy in type 2 diabetes and chronic kidney disease PLOS doihttpsdoiorg101371journalpone0110535
bull USRDS (2016) Annual data report 2016 Epidemiology of kidney disease in the United States Retrieved from United States Renal Data System httpswwwusrdsorgadraspx
bull Vasudev B amp Vasudev M (2012) A model curriculum for residents rotating in nephrology MedEDPORTAL doihttpdoiorg1015766mep_2374-82658288
bull Wei L MacDonald T M Jennings C Sheng X amp Flynn R W (2013) Estimated GFR reporting is associated with decreased nonsteroidal anti-inflammatory drug prescribing and increased renal function Kidney International (84)1 174-178
chronic kidney disease in primary care
CKD as a Public Health Issue
Slide Number 3
Costs of CKD in 2013 dollarsUSRDS report
Steps to CKD Patient Care
Renal anatomy and physiology
Definition of Chronic Kidney Disease
CKD Risk Factors
Gaps in CKD Diagnosis
Slide Number 10
Steps to CKD Patient Care
creatinine
Glomerular filtration rate
Slide Number 14
Slide Number 15
Use These Equations Cautiously if at all in hellip
lab albumin creatinine ratio
The New CKD Categories
Steps to CKD Patient Care
Slide Number 20
Kidney Involvement in Systemic Diseases
Slide Number 22
Slide Number 23
DysmorphicRenal Hematuria
Slide Number 25
If you have albuminuria or hematuria-order the following labs
bull Progression of disease ndash declining eGFR increasing proteinuria
bull Degree of proteinuria nephrotic syndrome gt 05-10 gd on ACEi or ARB therapy
bull Etiology of CKD not certain
bull Need help with disease management
bull Indications for kidney biopsy
Rosenberg 2016
WHEN TO REFER
STEPS TO CKD PATIENT CARE
1 CKD definition and risks2 Assess GFR albuminuria3 Determine etiology4 Assess for evidence of progression5 Assess for associated complications6 Discuss dialysistransplantation
KIDNEY TRANSPLANTATION
bull Treatment of choice for ESRDbull Improves quality of lifebull Waiting list time varies-3-5 yearsbull 3 year survival rate after transplantation is 83-94bull Increased risk of cancer
STARTING DIALYSIS IN THE ELDERLYhellipOR NOT
bull Among patients gt 75 yrs with stage 5 CKD who chose to NOT start dialysisbull Overall more likely to die over next 1-2 years bull But if they had ischemic heart disease or other significant comorbidity NO
DIFFERENCE in survival
bull Active disease management and supportive care may be appropriate without starting dialysis in the ill elderly
bull Palliative care does not mean ldquono carerdquo
bull Must have end-of-life discussions
(Murtagh et al 2007)
CKD MANAGEMENTbull Diagnose cause and treat underlying conditionbull Stage per guidelinesbull Slow progression of kidney disease (ACE inhibitors)bull Monitor for complicationsmdashvolume overload hyperkalemia metabolic acidosis
hyperphosphatemia anorexia fatigue htn bone diseasebull Labs cmp cbc phos Vit D 25OH iPTH urine microscopy uric acid urine
proteincr ratio-frequency based off heat map Get sono at least oncebull Vaccinate influenza hep B pneumococcalbull Eval ASCVD risk-likely needs statinbull Possible dexa (donrsquot give bisphosphonates if GFRlt35 let specialist manage)bull Refer to nephrology when eGFR is lt30 (sometimes if higher risk-refer earlier)
CASE 1
bull 55 year old man with past medical history of headaches presents to your office for his first time visit to a PCP in over 30 years
bull He has no past history of being admitted to the hospital and he does not take any OTC medsNSAIDsherbal meds He has no history of ETOH abuse smoking or drug use
bull Vitals BP 180100 mmHg pulse 80 R 18
bull Exam No JVD S1S2 regular PMI shifted to the left no gallop no abdominal bruit pulses bilaterally equal and regular no leg edema
bull What would you order
bull EKG cbc cmp ua urine proteincr ratio lipid
LAB RESULTS
bull Labs reveal a creatinine of 22 mgdL eGFR 33 Urine shows no blood or casts Urineprotein ratio shows 1 gm protein24 hrs EKG shows LVH
bull Next step in workupbull Renal ultrasound 1st then SPEP UPEP with immunofixation serum free light chains
bull Additional labs neg Renal ultrasound shows that both kidneys are slightly reduced in size and are mildly echogenic with no mass or hydronephrosis
bull What is your diagnosis
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileMain_complications_of_persistent_high_blood_pressurepngCreative Commons License associated httpcreativecommonsorglicensesby-sa30
bull 3 months Howevermdashwe have evidence of structural abnormalities Could potentially stage at G3b A3 (red on the heat map)
bull Goal blood pressure
bull JNC 8 14090 NKF 13080
bull Additional lab needed for progression monitoring
bull Cbc renal panel phos Vit D iPTH uric acid urine micro (we already have the renal sono and urine proteincr ratio and lipid)
Selective renal angiography (left lower renal artery) after successful percutaneous balloon dilatation of the stenotic lesionFibromuscular dysplasia in an accessory renal artery causing renovascular hypertension
Secondary Hypertension
Images retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileRenal_FMD2jpg and httpcommonswikimediaorgwikiFileRenal_FMDjpgCreative Commons License associated httpcreativecommonsorglicensesby20deeden (both images)
CASE 2bull OS is a 64year old Hispanic female in for DM check She has had DM for 15+ years and is currently
taking metformin 1000mg bid Lisinopril 10mg a day atorvastatin 40mg a day Labs today showed the following
bull Hgba1c 86 cmp eGFR 50 lipid WNL proteincr ratio 650mg These results are similar to her last visit
bull Upon further hx-you find that she had a recent eye exam and has mild nonproliferaive retinopathy She does not have neuropathy or other ss
bull What further workup do you need
bull Renal sonogram urine micro iPTH vit D (25 OH) phos uric acid
bull Dx stage
bull G3a A3
bull What further treatment do you need
bull Improve glycemic control Increase Lisinopril to 20mg with a goal of 40mg Avoid NSAIDs or other nephrotoxic agents make sure meds are renally dosed monitor 3xyear nephro referral
MANAGEMENT OF CKD IN DIABETESeGFR Recommended
All patients
Yearly measurement of creatinine urinary albumin excretion potassium
45-60 Referral to a nephrologist if possibility for nondiabetickidney disease existsConsider dose adjustment of medicationsMonitor eGFR every 6 monthsMonitor electrolytes bicarbonate hemoglobin calcium phosphorus parathyroid hormone at least yearly
Assure vitamin D sufficiencyConsider bone density testingReferral for dietary counselling
American Diabetes Association Standards of Medical Care in Diabetes Microvascular complications and foot care Diabetes Care 2017 40 (Suppl 1) S88-S98
CASE 3
bull 19 year old African American woman presents to your clinic with complaints of fatigue joint pains a new rash on her face oral ulcer
bull On exam BP 15080 P 88 Afebrile 96 O2 sats on RAbull GEN No respiratory distress at restbull HEENT painless oral ulcer flat rash over malar eminences sparing the nasolabial fold pallor +bull Lungs CTAbull CVS S1S2 regularbull Abdomen soft NTbull Ext left elbow joint and bilateral wrist joints are swollen and tender
bull What would you orderbull CBC CMP ua urine microscopy (microalbumin or urine proteincr ratio) ANA esr RF anti-ccp uric acid TSH
CASE 3
bull Working dx fatigue oral ulcer joint pain
bull Basic Labs Na 135 K 55 Bicarb 18 BUN 50 Cr 35 eGFR 22 Ca 90 ANA + titer 1640
bull UA 3+ blood 3+ protein RBC casts +
bull Given these results what is the most likely diagnosis
bull What would you do
SYSTEMIC LUPUS ERYTHEMATOSUS (SLE)
bull SLE multisystemic disease Etiology unknown
bull Production of autoantibodies and immune complexes formation
bull There is renal involvement in the great majority of patients with SLE at some time of the evolution 66-90
SLE ndash LUPUS NEPHRITIS
bull Race SLE is more commonsevere in African americans than Caucasiansbull
bull Gender female-to-male ratio of 91
bull Age Most patients develop lupus nephritis early in their disease course SLE is more common among women in the third decade of life and lupus nephritis occurs in patients aged 20-40 years
bull Kidney Biopsy For staging lupus nephritis (Class 1-5)
CASE 5bull A 80 year old man who has not seen a PCP in many years
presents to your clinic for weakness for the past few months On further questioning he tells you that his bones also have been hurting lately and he has developed leg swelling in the past month or so
bull On exam bull BP 16090 P 88 Afebrilebull GEN Thin built manbull HEENT pallor presentbull Lungs clearbull CVS S1S2 regular no rub or gallopbull Abdomen soft NTbull Ext 2 + edema
CASE 5
bull Differentials
bull CHF MI Cancer arthritis
bull Labs
bull CBC CMP urine microscopy urine proteincr ratio ESR TSH EKG BNP pa and lat CXR
bull LABS Urine dipstick negative for protein or blood
bull Basic chem bull Na 136 (135-145) K 51 (35-55) Chloride 108 (96-106) Bicarb 25
Given this presentation and the labs (low anion gap and elevated calcium anemia kidney failure) what will you think of What will you order next
Serum and urine protein electrophoresis
Intratubular refractile casts with surrounding syncytial giant cell reaction with chronic tubulointerstitial nephritis and fibrosis characteristic of myeloma cast nephropathy
Kidney Biopsy
CASE STUDYbull A 35 year old African American woman was seen in the clinic for
chronic cough and dyspnea on exertion She gave history of vague symptoms of fatigue and weight loss of 20 Ibs over the last six months
bull List some differentialsbull TB sarcoid lupus thyroid problems PEbull What would you orderbull PPD cbc cmp UA TSH ANA pa and lat cxr
bull Her labs were significant for mildly elevated calcium level and a creatinine of 20 mgdL eGFR 37
bull She had 750 mg of proteinuriaday
bull PPD neg ANA neg TSH and other labs WNL
bull Assuming this is present more than 3 monthshelliphellipwhat is her ckd stage
bull G3b A3
bull What do we still need
CT scan of chest
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileAnterior_mediastinal_mass_thymomajpgCreative Commons License associated httpcreativecommonsorglicensesby20deeden
CXR ndash HILAR LYMPHADENOPATHY
WHATS NEEDED NEXT
bull Biopsy of hilar lymphadenopathy or renal biopsy
bull DX sarcoidosis
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileSarcoidosis_signs_and_symptomsjpgThis work is in the public domain in the United States because it is a work of the United States Federal Government under the terms of Title 17 Chapter 1 Section 105 of the US Code
NEWLY DX CKD
bull 1) urinalysis microscopy ultrasound proteincr ratio
bull If obstruction-treat
bull No obstruction
bull Hx critical (consider myeloma if high risk)
bull glomerular bleeding or albumin in urine
bull Yes workup for glomerular causes (ANArf hep B C upep spep ANCA complement C3 C4)
bull No sterile pyruria-consider interstitial nephritis
bull High risk renovascular disease Evaluate renovascular disease
Additional Online Resources for CKD LearningbullNational Kidney Foundation wwwkidneyorgbullUnited States Renal Data Service wwwusrdsorgbullCDCrsquos CKD Surveillance Project
httpnccdcdcgovckdbullNational Kidney Disease Education Program
(NKDEP) httpnkdepnihgov
BIBLIOGRAPHY
bull Afzali B amp Goldsmith D J (2016 June 29) Statins and chronic kidney disease (G C Curhan amp A M Sheridan Eds) Retrieved 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsstatins-and-chronic-kidney-disease
bull American Diabetes Association Standards of Medical Care in Diabetes (2017) Microvascular complications and foot care Diabetes Care 2017 (40) S88-S98
bull American Diabetes Association Standards of Medical Care in Diabetes (2017) Microvascular complications and foot care Diabetes Care 40 (suppl 1) S88-S98
bull Berns J S (2017 Mar 22) Treatment of anemia in nondialysis chronic kidney disease (T A Golper amp A M Sheridan Eds) Retrieved from UpToDate httpswww-uptodate-comproxywichitaeducontentstreatment-of-anemia-in-nondialysis-chronic-kidney-disease
bull Chan M Dall A T Fletcher K E Lu N amp Trivedi H (2007) Outcomes in patients with chronic kidney disease referred late to nephrologists a meta-analysis American Journal of Medicine 120(12) 1063-1070
bull Coresh J Selvin E amp Stevens L A (2007) Prevalence of chronic kidny disease in the United States JAMA 298(17) doi101001jama298172038
bull de Brito-Ashurst I Varagunam M Raftery M amp Yagoob M (2009) Bicarbonate supplementation slows progression of CKD and improves nutritional status Journal of American Society of Nephrology (20) 2075-2084
BIBLIOGRAPHY
bull Duncan L Heathcoat J Djurdjev O amp Levin A (2001) Screening for renal disease using serum creatinine who are we missing Nephrology Dialysis and Transplant 16(5) 1042-1046
bull Dunkler D Gao P Lee S F Heinz G Clase C M Tobe S Oberbauer R (2015 August 7) Risk prediction for early CKD in type 2 diabetes Retrieved from Clinical Journal of the American Society of Nephrology httpcjasnasnjournalsorgcontent1081371fullsid=61422554-a5f1-41ac-b696-dcd3b12bd268
bull Fatehi P amp Chi-yuan H (September 15 2016) Diagnostic approach to the patient with newly identified chronic kidney disease (G C Curhan amp A M Sheridan Eds) Retrieved May 7 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsdiagnostic-approach-to-the-patient-with-newly-identified-chronic-kidney-disease
bull Fink J e (2009) Chronic Kidney Disease as an Under-Recognized Threat to Patient Safety American journal of kidney diseases the official journal of the National Kidney Foundation 53(4) 681-688
bull Gaffo A L amp Saag K G (2008 Nov) Management of hyperuricemia and gout in CKD doihttpdxdoiorg101053jajkd200807035
bull Hebert L A amp Parikh S V (2014 June 18) Differential diagnosis and evaluation of glomerular disease (R J Glassock amp A Q Lam Eds) Retrieved May 7 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsdifferential-diagnosis-and-evaluation-of-glomerular-disease
bull Inker L Perrone R D Sterns R H amp Forman J P (2017 March 7) Assessment of kidney function Retrieved from UpToDate httpswww-uptodate-comproxywichitaeducontentsassessment-of-kidney-functionsource=search_resultampsearch=creatinineampselectedTitle=1~150
BIBLIOGRAPHY
bull James P A Ortiz E amp Et Al (2014) Evidence based guideline for the management of high blood pressure in adults (JNC) JAMA 311(5) 507-520
bull Kidney Disease Improving Global Outcomes (KDIGO) CKD Work Group (2013 January) KDIGO 2012 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease Retrieved from Kidney International Supplement httpwwwkidney-internationalorg
bull Kunz R Friedrich C Wolbers M amp Mann J F (2008) Meta-analysis effect of monotherapy and combination therapy with inhibitors of the renin angiotensin system on proteinuria in renal disease Annals of Internal Medicine 148(1) 30-48
bull Levey A Stevens L A Schmid C H Castro A F Feldman H I Kusek J W Coresh J (2009) A new equation to estimate glomerular filtration rate Annals of Internal Medicine 150(9) 604-612
bull Levin A Bakris G L Molitch M Smulders M M Williams L A amp Andress D L (2007 Jan) Prevalence of abnormal serum vitamin D PTH calcium and phosphorus in patients with chronic kidney disease results of the study to evaluate early kidney disease Kidney International 71(1) 31-38 Retrieved from PubMED
bull Mahajan A Simoni J Sheather S Broglio K Rajab M amp Wesson D (2010) Daily oral sodium bicarbonate preserves glomerular filtration rate by slowing its decline in early hypertensive nephropathy Kidney International (78_ 303-309
bull Mann J Schmieder R E amp McQueen M (2008) Renal outcomes with telmisartan ramipril or both in people at high vascular risk (the ONTARGET study) a multicentre randomised doubleblind ocntrolled trial Lancet 372(9638) 547-533
BIBLIOGRAPHY
bull Matovinović M S (2009) Pathophysiology and classification of kidney disease Retrieved from The Journal of the International Federation of Clinical Chemistry and Laboratory Medicine httpwwwifccorgifccfilesdocs20010902pdf
bull Moe S Drueke T Lameire N amp Eknoyan G (2007 Jan) Chronic kidney disease-mineral-bone disorder a new paradigmdoi101053jackd200610005
bull Murtagh F E Marsh J E Donohoe P Ekbal N J Sheerin N S amp Harris F E (2007 July) Dialysis or not A comparative survival study of patients over 75 years with chronic kidney disease stage 5 Retrieved from Nephrology Dialysis and Transplant 22(7) httpswwwncbinlmnihgovpubmed17412702
bull National Kidney Foundation (2002) KDOQI clinical practice guidelines for chronic kidney disease evaluation classification andstratification American Journal of Kidney Disease S1-S266
bull National Kidney Foundation (2014 November 5) Fact Sheets Retrieved from httpwwwkidneyorgnewsnewsroomfactsheetsFastFacts
bull Pal S (2012 June 2) Trends in chronic kidney disease Retrieved from US Pharmacist (37)6 httpswwwuspharmacistcomarticletrends-in-chronic-kidney-disease
bull Qunibi W amp Henrich W L (2017 Jan 19) Overview of chronic kidney disease-mineral and bone disorder (J Berns amp A M Sheridan Eds) Retrieved from UpToDate httpswww-uptodate-comoverview-of-chronic-kidney-disease-mineral-and-bone-disorder-ckd-mbd
bull Rosenberg M (2016 Feb 24) Overview of the management of chronic kidney disease in adults (G C Curhan amp A M Sheridan Eds) Retrieved from UpToDate UpToDate httpswww-uptodate-comproxywichitaeducontentsoverview-of-the-management-of-chronic-kidney-disease-in-adults
BIBLIOGRAPHY
bull Szczech L Stewart R C Hsu-Lin S DeLosky R J Astor B C Fox C H Vassalotti J A (2014) Primary care detection of chronic kidney disease in adults with type 2 diabetes The ADD-CKD Study (Awareness Detection and Drug Therapy in type 2 diabetes and chronic kidney disease PLOS doihttpsdoiorg101371journalpone0110535
bull USRDS (2016) Annual data report 2016 Epidemiology of kidney disease in the United States Retrieved from United States Renal Data System httpswwwusrdsorgadraspx
bull Vasudev B amp Vasudev M (2012) A model curriculum for residents rotating in nephrology MedEDPORTAL doihttpdoiorg1015766mep_2374-82658288
bull Wei L MacDonald T M Jennings C Sheng X amp Flynn R W (2013) Estimated GFR reporting is associated with decreased nonsteroidal anti-inflammatory drug prescribing and increased renal function Kidney International (84)1 174-178
chronic kidney disease in primary care
CKD as a Public Health Issue
Slide Number 3
Costs of CKD in 2013 dollarsUSRDS report
Steps to CKD Patient Care
Renal anatomy and physiology
Definition of Chronic Kidney Disease
CKD Risk Factors
Gaps in CKD Diagnosis
Slide Number 10
Steps to CKD Patient Care
creatinine
Glomerular filtration rate
Slide Number 14
Slide Number 15
Use These Equations Cautiously if at all in hellip
lab albumin creatinine ratio
The New CKD Categories
Steps to CKD Patient Care
Slide Number 20
Kidney Involvement in Systemic Diseases
Slide Number 22
Slide Number 23
DysmorphicRenal Hematuria
Slide Number 25
If you have albuminuria or hematuria-order the following labs
bull Progression of disease ndash declining eGFR increasing proteinuria
bull Degree of proteinuria nephrotic syndrome gt 05-10 gd on ACEi or ARB therapy
bull Etiology of CKD not certain
bull Need help with disease management
bull Indications for kidney biopsy
Rosenberg 2016
WHEN TO REFER
STEPS TO CKD PATIENT CARE
1 CKD definition and risks2 Assess GFR albuminuria3 Determine etiology4 Assess for evidence of progression5 Assess for associated complications6 Discuss dialysistransplantation
KIDNEY TRANSPLANTATION
bull Treatment of choice for ESRDbull Improves quality of lifebull Waiting list time varies-3-5 yearsbull 3 year survival rate after transplantation is 83-94bull Increased risk of cancer
STARTING DIALYSIS IN THE ELDERLYhellipOR NOT
bull Among patients gt 75 yrs with stage 5 CKD who chose to NOT start dialysisbull Overall more likely to die over next 1-2 years bull But if they had ischemic heart disease or other significant comorbidity NO
DIFFERENCE in survival
bull Active disease management and supportive care may be appropriate without starting dialysis in the ill elderly
bull Palliative care does not mean ldquono carerdquo
bull Must have end-of-life discussions
(Murtagh et al 2007)
CKD MANAGEMENTbull Diagnose cause and treat underlying conditionbull Stage per guidelinesbull Slow progression of kidney disease (ACE inhibitors)bull Monitor for complicationsmdashvolume overload hyperkalemia metabolic acidosis
hyperphosphatemia anorexia fatigue htn bone diseasebull Labs cmp cbc phos Vit D 25OH iPTH urine microscopy uric acid urine
proteincr ratio-frequency based off heat map Get sono at least oncebull Vaccinate influenza hep B pneumococcalbull Eval ASCVD risk-likely needs statinbull Possible dexa (donrsquot give bisphosphonates if GFRlt35 let specialist manage)bull Refer to nephrology when eGFR is lt30 (sometimes if higher risk-refer earlier)
CASE 1
bull 55 year old man with past medical history of headaches presents to your office for his first time visit to a PCP in over 30 years
bull He has no past history of being admitted to the hospital and he does not take any OTC medsNSAIDsherbal meds He has no history of ETOH abuse smoking or drug use
bull Vitals BP 180100 mmHg pulse 80 R 18
bull Exam No JVD S1S2 regular PMI shifted to the left no gallop no abdominal bruit pulses bilaterally equal and regular no leg edema
bull What would you order
bull EKG cbc cmp ua urine proteincr ratio lipid
LAB RESULTS
bull Labs reveal a creatinine of 22 mgdL eGFR 33 Urine shows no blood or casts Urineprotein ratio shows 1 gm protein24 hrs EKG shows LVH
bull Next step in workupbull Renal ultrasound 1st then SPEP UPEP with immunofixation serum free light chains
bull Additional labs neg Renal ultrasound shows that both kidneys are slightly reduced in size and are mildly echogenic with no mass or hydronephrosis
bull What is your diagnosis
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileMain_complications_of_persistent_high_blood_pressurepngCreative Commons License associated httpcreativecommonsorglicensesby-sa30
bull 3 months Howevermdashwe have evidence of structural abnormalities Could potentially stage at G3b A3 (red on the heat map)
bull Goal blood pressure
bull JNC 8 14090 NKF 13080
bull Additional lab needed for progression monitoring
bull Cbc renal panel phos Vit D iPTH uric acid urine micro (we already have the renal sono and urine proteincr ratio and lipid)
Selective renal angiography (left lower renal artery) after successful percutaneous balloon dilatation of the stenotic lesionFibromuscular dysplasia in an accessory renal artery causing renovascular hypertension
Secondary Hypertension
Images retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileRenal_FMD2jpg and httpcommonswikimediaorgwikiFileRenal_FMDjpgCreative Commons License associated httpcreativecommonsorglicensesby20deeden (both images)
CASE 2bull OS is a 64year old Hispanic female in for DM check She has had DM for 15+ years and is currently
taking metformin 1000mg bid Lisinopril 10mg a day atorvastatin 40mg a day Labs today showed the following
bull Hgba1c 86 cmp eGFR 50 lipid WNL proteincr ratio 650mg These results are similar to her last visit
bull Upon further hx-you find that she had a recent eye exam and has mild nonproliferaive retinopathy She does not have neuropathy or other ss
bull What further workup do you need
bull Renal sonogram urine micro iPTH vit D (25 OH) phos uric acid
bull Dx stage
bull G3a A3
bull What further treatment do you need
bull Improve glycemic control Increase Lisinopril to 20mg with a goal of 40mg Avoid NSAIDs or other nephrotoxic agents make sure meds are renally dosed monitor 3xyear nephro referral
MANAGEMENT OF CKD IN DIABETESeGFR Recommended
All patients
Yearly measurement of creatinine urinary albumin excretion potassium
45-60 Referral to a nephrologist if possibility for nondiabetickidney disease existsConsider dose adjustment of medicationsMonitor eGFR every 6 monthsMonitor electrolytes bicarbonate hemoglobin calcium phosphorus parathyroid hormone at least yearly
Assure vitamin D sufficiencyConsider bone density testingReferral for dietary counselling
American Diabetes Association Standards of Medical Care in Diabetes Microvascular complications and foot care Diabetes Care 2017 40 (Suppl 1) S88-S98
CASE 3
bull 19 year old African American woman presents to your clinic with complaints of fatigue joint pains a new rash on her face oral ulcer
bull On exam BP 15080 P 88 Afebrile 96 O2 sats on RAbull GEN No respiratory distress at restbull HEENT painless oral ulcer flat rash over malar eminences sparing the nasolabial fold pallor +bull Lungs CTAbull CVS S1S2 regularbull Abdomen soft NTbull Ext left elbow joint and bilateral wrist joints are swollen and tender
bull What would you orderbull CBC CMP ua urine microscopy (microalbumin or urine proteincr ratio) ANA esr RF anti-ccp uric acid TSH
CASE 3
bull Working dx fatigue oral ulcer joint pain
bull Basic Labs Na 135 K 55 Bicarb 18 BUN 50 Cr 35 eGFR 22 Ca 90 ANA + titer 1640
bull UA 3+ blood 3+ protein RBC casts +
bull Given these results what is the most likely diagnosis
bull What would you do
SYSTEMIC LUPUS ERYTHEMATOSUS (SLE)
bull SLE multisystemic disease Etiology unknown
bull Production of autoantibodies and immune complexes formation
bull There is renal involvement in the great majority of patients with SLE at some time of the evolution 66-90
SLE ndash LUPUS NEPHRITIS
bull Race SLE is more commonsevere in African americans than Caucasiansbull
bull Gender female-to-male ratio of 91
bull Age Most patients develop lupus nephritis early in their disease course SLE is more common among women in the third decade of life and lupus nephritis occurs in patients aged 20-40 years
bull Kidney Biopsy For staging lupus nephritis (Class 1-5)
CASE 5bull A 80 year old man who has not seen a PCP in many years
presents to your clinic for weakness for the past few months On further questioning he tells you that his bones also have been hurting lately and he has developed leg swelling in the past month or so
bull On exam bull BP 16090 P 88 Afebrilebull GEN Thin built manbull HEENT pallor presentbull Lungs clearbull CVS S1S2 regular no rub or gallopbull Abdomen soft NTbull Ext 2 + edema
CASE 5
bull Differentials
bull CHF MI Cancer arthritis
bull Labs
bull CBC CMP urine microscopy urine proteincr ratio ESR TSH EKG BNP pa and lat CXR
bull LABS Urine dipstick negative for protein or blood
bull Basic chem bull Na 136 (135-145) K 51 (35-55) Chloride 108 (96-106) Bicarb 25
Given this presentation and the labs (low anion gap and elevated calcium anemia kidney failure) what will you think of What will you order next
Serum and urine protein electrophoresis
Intratubular refractile casts with surrounding syncytial giant cell reaction with chronic tubulointerstitial nephritis and fibrosis characteristic of myeloma cast nephropathy
Kidney Biopsy
CASE STUDYbull A 35 year old African American woman was seen in the clinic for
chronic cough and dyspnea on exertion She gave history of vague symptoms of fatigue and weight loss of 20 Ibs over the last six months
bull List some differentialsbull TB sarcoid lupus thyroid problems PEbull What would you orderbull PPD cbc cmp UA TSH ANA pa and lat cxr
bull Her labs were significant for mildly elevated calcium level and a creatinine of 20 mgdL eGFR 37
bull She had 750 mg of proteinuriaday
bull PPD neg ANA neg TSH and other labs WNL
bull Assuming this is present more than 3 monthshelliphellipwhat is her ckd stage
bull G3b A3
bull What do we still need
CT scan of chest
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileAnterior_mediastinal_mass_thymomajpgCreative Commons License associated httpcreativecommonsorglicensesby20deeden
CXR ndash HILAR LYMPHADENOPATHY
WHATS NEEDED NEXT
bull Biopsy of hilar lymphadenopathy or renal biopsy
bull DX sarcoidosis
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileSarcoidosis_signs_and_symptomsjpgThis work is in the public domain in the United States because it is a work of the United States Federal Government under the terms of Title 17 Chapter 1 Section 105 of the US Code
NEWLY DX CKD
bull 1) urinalysis microscopy ultrasound proteincr ratio
bull If obstruction-treat
bull No obstruction
bull Hx critical (consider myeloma if high risk)
bull glomerular bleeding or albumin in urine
bull Yes workup for glomerular causes (ANArf hep B C upep spep ANCA complement C3 C4)
bull No sterile pyruria-consider interstitial nephritis
bull High risk renovascular disease Evaluate renovascular disease
Additional Online Resources for CKD LearningbullNational Kidney Foundation wwwkidneyorgbullUnited States Renal Data Service wwwusrdsorgbullCDCrsquos CKD Surveillance Project
httpnccdcdcgovckdbullNational Kidney Disease Education Program
(NKDEP) httpnkdepnihgov
BIBLIOGRAPHY
bull Afzali B amp Goldsmith D J (2016 June 29) Statins and chronic kidney disease (G C Curhan amp A M Sheridan Eds) Retrieved 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsstatins-and-chronic-kidney-disease
bull American Diabetes Association Standards of Medical Care in Diabetes (2017) Microvascular complications and foot care Diabetes Care 2017 (40) S88-S98
bull American Diabetes Association Standards of Medical Care in Diabetes (2017) Microvascular complications and foot care Diabetes Care 40 (suppl 1) S88-S98
bull Berns J S (2017 Mar 22) Treatment of anemia in nondialysis chronic kidney disease (T A Golper amp A M Sheridan Eds) Retrieved from UpToDate httpswww-uptodate-comproxywichitaeducontentstreatment-of-anemia-in-nondialysis-chronic-kidney-disease
bull Chan M Dall A T Fletcher K E Lu N amp Trivedi H (2007) Outcomes in patients with chronic kidney disease referred late to nephrologists a meta-analysis American Journal of Medicine 120(12) 1063-1070
bull Coresh J Selvin E amp Stevens L A (2007) Prevalence of chronic kidny disease in the United States JAMA 298(17) doi101001jama298172038
bull de Brito-Ashurst I Varagunam M Raftery M amp Yagoob M (2009) Bicarbonate supplementation slows progression of CKD and improves nutritional status Journal of American Society of Nephrology (20) 2075-2084
BIBLIOGRAPHY
bull Duncan L Heathcoat J Djurdjev O amp Levin A (2001) Screening for renal disease using serum creatinine who are we missing Nephrology Dialysis and Transplant 16(5) 1042-1046
bull Dunkler D Gao P Lee S F Heinz G Clase C M Tobe S Oberbauer R (2015 August 7) Risk prediction for early CKD in type 2 diabetes Retrieved from Clinical Journal of the American Society of Nephrology httpcjasnasnjournalsorgcontent1081371fullsid=61422554-a5f1-41ac-b696-dcd3b12bd268
bull Fatehi P amp Chi-yuan H (September 15 2016) Diagnostic approach to the patient with newly identified chronic kidney disease (G C Curhan amp A M Sheridan Eds) Retrieved May 7 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsdiagnostic-approach-to-the-patient-with-newly-identified-chronic-kidney-disease
bull Fink J e (2009) Chronic Kidney Disease as an Under-Recognized Threat to Patient Safety American journal of kidney diseases the official journal of the National Kidney Foundation 53(4) 681-688
bull Gaffo A L amp Saag K G (2008 Nov) Management of hyperuricemia and gout in CKD doihttpdxdoiorg101053jajkd200807035
bull Hebert L A amp Parikh S V (2014 June 18) Differential diagnosis and evaluation of glomerular disease (R J Glassock amp A Q Lam Eds) Retrieved May 7 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsdifferential-diagnosis-and-evaluation-of-glomerular-disease
bull Inker L Perrone R D Sterns R H amp Forman J P (2017 March 7) Assessment of kidney function Retrieved from UpToDate httpswww-uptodate-comproxywichitaeducontentsassessment-of-kidney-functionsource=search_resultampsearch=creatinineampselectedTitle=1~150
BIBLIOGRAPHY
bull James P A Ortiz E amp Et Al (2014) Evidence based guideline for the management of high blood pressure in adults (JNC) JAMA 311(5) 507-520
bull Kidney Disease Improving Global Outcomes (KDIGO) CKD Work Group (2013 January) KDIGO 2012 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease Retrieved from Kidney International Supplement httpwwwkidney-internationalorg
bull Kunz R Friedrich C Wolbers M amp Mann J F (2008) Meta-analysis effect of monotherapy and combination therapy with inhibitors of the renin angiotensin system on proteinuria in renal disease Annals of Internal Medicine 148(1) 30-48
bull Levey A Stevens L A Schmid C H Castro A F Feldman H I Kusek J W Coresh J (2009) A new equation to estimate glomerular filtration rate Annals of Internal Medicine 150(9) 604-612
bull Levin A Bakris G L Molitch M Smulders M M Williams L A amp Andress D L (2007 Jan) Prevalence of abnormal serum vitamin D PTH calcium and phosphorus in patients with chronic kidney disease results of the study to evaluate early kidney disease Kidney International 71(1) 31-38 Retrieved from PubMED
bull Mahajan A Simoni J Sheather S Broglio K Rajab M amp Wesson D (2010) Daily oral sodium bicarbonate preserves glomerular filtration rate by slowing its decline in early hypertensive nephropathy Kidney International (78_ 303-309
bull Mann J Schmieder R E amp McQueen M (2008) Renal outcomes with telmisartan ramipril or both in people at high vascular risk (the ONTARGET study) a multicentre randomised doubleblind ocntrolled trial Lancet 372(9638) 547-533
BIBLIOGRAPHY
bull Matovinović M S (2009) Pathophysiology and classification of kidney disease Retrieved from The Journal of the International Federation of Clinical Chemistry and Laboratory Medicine httpwwwifccorgifccfilesdocs20010902pdf
bull Moe S Drueke T Lameire N amp Eknoyan G (2007 Jan) Chronic kidney disease-mineral-bone disorder a new paradigmdoi101053jackd200610005
bull Murtagh F E Marsh J E Donohoe P Ekbal N J Sheerin N S amp Harris F E (2007 July) Dialysis or not A comparative survival study of patients over 75 years with chronic kidney disease stage 5 Retrieved from Nephrology Dialysis and Transplant 22(7) httpswwwncbinlmnihgovpubmed17412702
bull National Kidney Foundation (2002) KDOQI clinical practice guidelines for chronic kidney disease evaluation classification andstratification American Journal of Kidney Disease S1-S266
bull National Kidney Foundation (2014 November 5) Fact Sheets Retrieved from httpwwwkidneyorgnewsnewsroomfactsheetsFastFacts
bull Pal S (2012 June 2) Trends in chronic kidney disease Retrieved from US Pharmacist (37)6 httpswwwuspharmacistcomarticletrends-in-chronic-kidney-disease
bull Qunibi W amp Henrich W L (2017 Jan 19) Overview of chronic kidney disease-mineral and bone disorder (J Berns amp A M Sheridan Eds) Retrieved from UpToDate httpswww-uptodate-comoverview-of-chronic-kidney-disease-mineral-and-bone-disorder-ckd-mbd
bull Rosenberg M (2016 Feb 24) Overview of the management of chronic kidney disease in adults (G C Curhan amp A M Sheridan Eds) Retrieved from UpToDate UpToDate httpswww-uptodate-comproxywichitaeducontentsoverview-of-the-management-of-chronic-kidney-disease-in-adults
BIBLIOGRAPHY
bull Szczech L Stewart R C Hsu-Lin S DeLosky R J Astor B C Fox C H Vassalotti J A (2014) Primary care detection of chronic kidney disease in adults with type 2 diabetes The ADD-CKD Study (Awareness Detection and Drug Therapy in type 2 diabetes and chronic kidney disease PLOS doihttpsdoiorg101371journalpone0110535
bull USRDS (2016) Annual data report 2016 Epidemiology of kidney disease in the United States Retrieved from United States Renal Data System httpswwwusrdsorgadraspx
bull Vasudev B amp Vasudev M (2012) A model curriculum for residents rotating in nephrology MedEDPORTAL doihttpdoiorg1015766mep_2374-82658288
bull Wei L MacDonald T M Jennings C Sheng X amp Flynn R W (2013) Estimated GFR reporting is associated with decreased nonsteroidal anti-inflammatory drug prescribing and increased renal function Kidney International (84)1 174-178
chronic kidney disease in primary care
CKD as a Public Health Issue
Slide Number 3
Costs of CKD in 2013 dollarsUSRDS report
Steps to CKD Patient Care
Renal anatomy and physiology
Definition of Chronic Kidney Disease
CKD Risk Factors
Gaps in CKD Diagnosis
Slide Number 10
Steps to CKD Patient Care
creatinine
Glomerular filtration rate
Slide Number 14
Slide Number 15
Use These Equations Cautiously if at all in hellip
lab albumin creatinine ratio
The New CKD Categories
Steps to CKD Patient Care
Slide Number 20
Kidney Involvement in Systemic Diseases
Slide Number 22
Slide Number 23
DysmorphicRenal Hematuria
Slide Number 25
If you have albuminuria or hematuria-order the following labs
bull Progression of disease ndash declining eGFR increasing proteinuria
bull Degree of proteinuria nephrotic syndrome gt 05-10 gd on ACEi or ARB therapy
bull Etiology of CKD not certain
bull Need help with disease management
bull Indications for kidney biopsy
Rosenberg 2016
WHEN TO REFER
STEPS TO CKD PATIENT CARE
1 CKD definition and risks2 Assess GFR albuminuria3 Determine etiology4 Assess for evidence of progression5 Assess for associated complications6 Discuss dialysistransplantation
KIDNEY TRANSPLANTATION
bull Treatment of choice for ESRDbull Improves quality of lifebull Waiting list time varies-3-5 yearsbull 3 year survival rate after transplantation is 83-94bull Increased risk of cancer
STARTING DIALYSIS IN THE ELDERLYhellipOR NOT
bull Among patients gt 75 yrs with stage 5 CKD who chose to NOT start dialysisbull Overall more likely to die over next 1-2 years bull But if they had ischemic heart disease or other significant comorbidity NO
DIFFERENCE in survival
bull Active disease management and supportive care may be appropriate without starting dialysis in the ill elderly
bull Palliative care does not mean ldquono carerdquo
bull Must have end-of-life discussions
(Murtagh et al 2007)
CKD MANAGEMENTbull Diagnose cause and treat underlying conditionbull Stage per guidelinesbull Slow progression of kidney disease (ACE inhibitors)bull Monitor for complicationsmdashvolume overload hyperkalemia metabolic acidosis
hyperphosphatemia anorexia fatigue htn bone diseasebull Labs cmp cbc phos Vit D 25OH iPTH urine microscopy uric acid urine
proteincr ratio-frequency based off heat map Get sono at least oncebull Vaccinate influenza hep B pneumococcalbull Eval ASCVD risk-likely needs statinbull Possible dexa (donrsquot give bisphosphonates if GFRlt35 let specialist manage)bull Refer to nephrology when eGFR is lt30 (sometimes if higher risk-refer earlier)
CASE 1
bull 55 year old man with past medical history of headaches presents to your office for his first time visit to a PCP in over 30 years
bull He has no past history of being admitted to the hospital and he does not take any OTC medsNSAIDsherbal meds He has no history of ETOH abuse smoking or drug use
bull Vitals BP 180100 mmHg pulse 80 R 18
bull Exam No JVD S1S2 regular PMI shifted to the left no gallop no abdominal bruit pulses bilaterally equal and regular no leg edema
bull What would you order
bull EKG cbc cmp ua urine proteincr ratio lipid
LAB RESULTS
bull Labs reveal a creatinine of 22 mgdL eGFR 33 Urine shows no blood or casts Urineprotein ratio shows 1 gm protein24 hrs EKG shows LVH
bull Next step in workupbull Renal ultrasound 1st then SPEP UPEP with immunofixation serum free light chains
bull Additional labs neg Renal ultrasound shows that both kidneys are slightly reduced in size and are mildly echogenic with no mass or hydronephrosis
bull What is your diagnosis
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileMain_complications_of_persistent_high_blood_pressurepngCreative Commons License associated httpcreativecommonsorglicensesby-sa30
bull 3 months Howevermdashwe have evidence of structural abnormalities Could potentially stage at G3b A3 (red on the heat map)
bull Goal blood pressure
bull JNC 8 14090 NKF 13080
bull Additional lab needed for progression monitoring
bull Cbc renal panel phos Vit D iPTH uric acid urine micro (we already have the renal sono and urine proteincr ratio and lipid)
Selective renal angiography (left lower renal artery) after successful percutaneous balloon dilatation of the stenotic lesionFibromuscular dysplasia in an accessory renal artery causing renovascular hypertension
Secondary Hypertension
Images retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileRenal_FMD2jpg and httpcommonswikimediaorgwikiFileRenal_FMDjpgCreative Commons License associated httpcreativecommonsorglicensesby20deeden (both images)
CASE 2bull OS is a 64year old Hispanic female in for DM check She has had DM for 15+ years and is currently
taking metformin 1000mg bid Lisinopril 10mg a day atorvastatin 40mg a day Labs today showed the following
bull Hgba1c 86 cmp eGFR 50 lipid WNL proteincr ratio 650mg These results are similar to her last visit
bull Upon further hx-you find that she had a recent eye exam and has mild nonproliferaive retinopathy She does not have neuropathy or other ss
bull What further workup do you need
bull Renal sonogram urine micro iPTH vit D (25 OH) phos uric acid
bull Dx stage
bull G3a A3
bull What further treatment do you need
bull Improve glycemic control Increase Lisinopril to 20mg with a goal of 40mg Avoid NSAIDs or other nephrotoxic agents make sure meds are renally dosed monitor 3xyear nephro referral
MANAGEMENT OF CKD IN DIABETESeGFR Recommended
All patients
Yearly measurement of creatinine urinary albumin excretion potassium
45-60 Referral to a nephrologist if possibility for nondiabetickidney disease existsConsider dose adjustment of medicationsMonitor eGFR every 6 monthsMonitor electrolytes bicarbonate hemoglobin calcium phosphorus parathyroid hormone at least yearly
Assure vitamin D sufficiencyConsider bone density testingReferral for dietary counselling
American Diabetes Association Standards of Medical Care in Diabetes Microvascular complications and foot care Diabetes Care 2017 40 (Suppl 1) S88-S98
CASE 3
bull 19 year old African American woman presents to your clinic with complaints of fatigue joint pains a new rash on her face oral ulcer
bull On exam BP 15080 P 88 Afebrile 96 O2 sats on RAbull GEN No respiratory distress at restbull HEENT painless oral ulcer flat rash over malar eminences sparing the nasolabial fold pallor +bull Lungs CTAbull CVS S1S2 regularbull Abdomen soft NTbull Ext left elbow joint and bilateral wrist joints are swollen and tender
bull What would you orderbull CBC CMP ua urine microscopy (microalbumin or urine proteincr ratio) ANA esr RF anti-ccp uric acid TSH
CASE 3
bull Working dx fatigue oral ulcer joint pain
bull Basic Labs Na 135 K 55 Bicarb 18 BUN 50 Cr 35 eGFR 22 Ca 90 ANA + titer 1640
bull UA 3+ blood 3+ protein RBC casts +
bull Given these results what is the most likely diagnosis
bull What would you do
SYSTEMIC LUPUS ERYTHEMATOSUS (SLE)
bull SLE multisystemic disease Etiology unknown
bull Production of autoantibodies and immune complexes formation
bull There is renal involvement in the great majority of patients with SLE at some time of the evolution 66-90
SLE ndash LUPUS NEPHRITIS
bull Race SLE is more commonsevere in African americans than Caucasiansbull
bull Gender female-to-male ratio of 91
bull Age Most patients develop lupus nephritis early in their disease course SLE is more common among women in the third decade of life and lupus nephritis occurs in patients aged 20-40 years
bull Kidney Biopsy For staging lupus nephritis (Class 1-5)
CASE 5bull A 80 year old man who has not seen a PCP in many years
presents to your clinic for weakness for the past few months On further questioning he tells you that his bones also have been hurting lately and he has developed leg swelling in the past month or so
bull On exam bull BP 16090 P 88 Afebrilebull GEN Thin built manbull HEENT pallor presentbull Lungs clearbull CVS S1S2 regular no rub or gallopbull Abdomen soft NTbull Ext 2 + edema
CASE 5
bull Differentials
bull CHF MI Cancer arthritis
bull Labs
bull CBC CMP urine microscopy urine proteincr ratio ESR TSH EKG BNP pa and lat CXR
bull LABS Urine dipstick negative for protein or blood
bull Basic chem bull Na 136 (135-145) K 51 (35-55) Chloride 108 (96-106) Bicarb 25
Given this presentation and the labs (low anion gap and elevated calcium anemia kidney failure) what will you think of What will you order next
Serum and urine protein electrophoresis
Intratubular refractile casts with surrounding syncytial giant cell reaction with chronic tubulointerstitial nephritis and fibrosis characteristic of myeloma cast nephropathy
Kidney Biopsy
CASE STUDYbull A 35 year old African American woman was seen in the clinic for
chronic cough and dyspnea on exertion She gave history of vague symptoms of fatigue and weight loss of 20 Ibs over the last six months
bull List some differentialsbull TB sarcoid lupus thyroid problems PEbull What would you orderbull PPD cbc cmp UA TSH ANA pa and lat cxr
bull Her labs were significant for mildly elevated calcium level and a creatinine of 20 mgdL eGFR 37
bull She had 750 mg of proteinuriaday
bull PPD neg ANA neg TSH and other labs WNL
bull Assuming this is present more than 3 monthshelliphellipwhat is her ckd stage
bull G3b A3
bull What do we still need
CT scan of chest
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileAnterior_mediastinal_mass_thymomajpgCreative Commons License associated httpcreativecommonsorglicensesby20deeden
CXR ndash HILAR LYMPHADENOPATHY
WHATS NEEDED NEXT
bull Biopsy of hilar lymphadenopathy or renal biopsy
bull DX sarcoidosis
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileSarcoidosis_signs_and_symptomsjpgThis work is in the public domain in the United States because it is a work of the United States Federal Government under the terms of Title 17 Chapter 1 Section 105 of the US Code
NEWLY DX CKD
bull 1) urinalysis microscopy ultrasound proteincr ratio
bull If obstruction-treat
bull No obstruction
bull Hx critical (consider myeloma if high risk)
bull glomerular bleeding or albumin in urine
bull Yes workup for glomerular causes (ANArf hep B C upep spep ANCA complement C3 C4)
bull No sterile pyruria-consider interstitial nephritis
bull High risk renovascular disease Evaluate renovascular disease
Additional Online Resources for CKD LearningbullNational Kidney Foundation wwwkidneyorgbullUnited States Renal Data Service wwwusrdsorgbullCDCrsquos CKD Surveillance Project
httpnccdcdcgovckdbullNational Kidney Disease Education Program
(NKDEP) httpnkdepnihgov
BIBLIOGRAPHY
bull Afzali B amp Goldsmith D J (2016 June 29) Statins and chronic kidney disease (G C Curhan amp A M Sheridan Eds) Retrieved 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsstatins-and-chronic-kidney-disease
bull American Diabetes Association Standards of Medical Care in Diabetes (2017) Microvascular complications and foot care Diabetes Care 2017 (40) S88-S98
bull American Diabetes Association Standards of Medical Care in Diabetes (2017) Microvascular complications and foot care Diabetes Care 40 (suppl 1) S88-S98
bull Berns J S (2017 Mar 22) Treatment of anemia in nondialysis chronic kidney disease (T A Golper amp A M Sheridan Eds) Retrieved from UpToDate httpswww-uptodate-comproxywichitaeducontentstreatment-of-anemia-in-nondialysis-chronic-kidney-disease
bull Chan M Dall A T Fletcher K E Lu N amp Trivedi H (2007) Outcomes in patients with chronic kidney disease referred late to nephrologists a meta-analysis American Journal of Medicine 120(12) 1063-1070
bull Coresh J Selvin E amp Stevens L A (2007) Prevalence of chronic kidny disease in the United States JAMA 298(17) doi101001jama298172038
bull de Brito-Ashurst I Varagunam M Raftery M amp Yagoob M (2009) Bicarbonate supplementation slows progression of CKD and improves nutritional status Journal of American Society of Nephrology (20) 2075-2084
BIBLIOGRAPHY
bull Duncan L Heathcoat J Djurdjev O amp Levin A (2001) Screening for renal disease using serum creatinine who are we missing Nephrology Dialysis and Transplant 16(5) 1042-1046
bull Dunkler D Gao P Lee S F Heinz G Clase C M Tobe S Oberbauer R (2015 August 7) Risk prediction for early CKD in type 2 diabetes Retrieved from Clinical Journal of the American Society of Nephrology httpcjasnasnjournalsorgcontent1081371fullsid=61422554-a5f1-41ac-b696-dcd3b12bd268
bull Fatehi P amp Chi-yuan H (September 15 2016) Diagnostic approach to the patient with newly identified chronic kidney disease (G C Curhan amp A M Sheridan Eds) Retrieved May 7 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsdiagnostic-approach-to-the-patient-with-newly-identified-chronic-kidney-disease
bull Fink J e (2009) Chronic Kidney Disease as an Under-Recognized Threat to Patient Safety American journal of kidney diseases the official journal of the National Kidney Foundation 53(4) 681-688
bull Gaffo A L amp Saag K G (2008 Nov) Management of hyperuricemia and gout in CKD doihttpdxdoiorg101053jajkd200807035
bull Hebert L A amp Parikh S V (2014 June 18) Differential diagnosis and evaluation of glomerular disease (R J Glassock amp A Q Lam Eds) Retrieved May 7 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsdifferential-diagnosis-and-evaluation-of-glomerular-disease
bull Inker L Perrone R D Sterns R H amp Forman J P (2017 March 7) Assessment of kidney function Retrieved from UpToDate httpswww-uptodate-comproxywichitaeducontentsassessment-of-kidney-functionsource=search_resultampsearch=creatinineampselectedTitle=1~150
BIBLIOGRAPHY
bull James P A Ortiz E amp Et Al (2014) Evidence based guideline for the management of high blood pressure in adults (JNC) JAMA 311(5) 507-520
bull Kidney Disease Improving Global Outcomes (KDIGO) CKD Work Group (2013 January) KDIGO 2012 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease Retrieved from Kidney International Supplement httpwwwkidney-internationalorg
bull Kunz R Friedrich C Wolbers M amp Mann J F (2008) Meta-analysis effect of monotherapy and combination therapy with inhibitors of the renin angiotensin system on proteinuria in renal disease Annals of Internal Medicine 148(1) 30-48
bull Levey A Stevens L A Schmid C H Castro A F Feldman H I Kusek J W Coresh J (2009) A new equation to estimate glomerular filtration rate Annals of Internal Medicine 150(9) 604-612
bull Levin A Bakris G L Molitch M Smulders M M Williams L A amp Andress D L (2007 Jan) Prevalence of abnormal serum vitamin D PTH calcium and phosphorus in patients with chronic kidney disease results of the study to evaluate early kidney disease Kidney International 71(1) 31-38 Retrieved from PubMED
bull Mahajan A Simoni J Sheather S Broglio K Rajab M amp Wesson D (2010) Daily oral sodium bicarbonate preserves glomerular filtration rate by slowing its decline in early hypertensive nephropathy Kidney International (78_ 303-309
bull Mann J Schmieder R E amp McQueen M (2008) Renal outcomes with telmisartan ramipril or both in people at high vascular risk (the ONTARGET study) a multicentre randomised doubleblind ocntrolled trial Lancet 372(9638) 547-533
BIBLIOGRAPHY
bull Matovinović M S (2009) Pathophysiology and classification of kidney disease Retrieved from The Journal of the International Federation of Clinical Chemistry and Laboratory Medicine httpwwwifccorgifccfilesdocs20010902pdf
bull Moe S Drueke T Lameire N amp Eknoyan G (2007 Jan) Chronic kidney disease-mineral-bone disorder a new paradigmdoi101053jackd200610005
bull Murtagh F E Marsh J E Donohoe P Ekbal N J Sheerin N S amp Harris F E (2007 July) Dialysis or not A comparative survival study of patients over 75 years with chronic kidney disease stage 5 Retrieved from Nephrology Dialysis and Transplant 22(7) httpswwwncbinlmnihgovpubmed17412702
bull National Kidney Foundation (2002) KDOQI clinical practice guidelines for chronic kidney disease evaluation classification andstratification American Journal of Kidney Disease S1-S266
bull National Kidney Foundation (2014 November 5) Fact Sheets Retrieved from httpwwwkidneyorgnewsnewsroomfactsheetsFastFacts
bull Pal S (2012 June 2) Trends in chronic kidney disease Retrieved from US Pharmacist (37)6 httpswwwuspharmacistcomarticletrends-in-chronic-kidney-disease
bull Qunibi W amp Henrich W L (2017 Jan 19) Overview of chronic kidney disease-mineral and bone disorder (J Berns amp A M Sheridan Eds) Retrieved from UpToDate httpswww-uptodate-comoverview-of-chronic-kidney-disease-mineral-and-bone-disorder-ckd-mbd
bull Rosenberg M (2016 Feb 24) Overview of the management of chronic kidney disease in adults (G C Curhan amp A M Sheridan Eds) Retrieved from UpToDate UpToDate httpswww-uptodate-comproxywichitaeducontentsoverview-of-the-management-of-chronic-kidney-disease-in-adults
BIBLIOGRAPHY
bull Szczech L Stewart R C Hsu-Lin S DeLosky R J Astor B C Fox C H Vassalotti J A (2014) Primary care detection of chronic kidney disease in adults with type 2 diabetes The ADD-CKD Study (Awareness Detection and Drug Therapy in type 2 diabetes and chronic kidney disease PLOS doihttpsdoiorg101371journalpone0110535
bull USRDS (2016) Annual data report 2016 Epidemiology of kidney disease in the United States Retrieved from United States Renal Data System httpswwwusrdsorgadraspx
bull Vasudev B amp Vasudev M (2012) A model curriculum for residents rotating in nephrology MedEDPORTAL doihttpdoiorg1015766mep_2374-82658288
bull Wei L MacDonald T M Jennings C Sheng X amp Flynn R W (2013) Estimated GFR reporting is associated with decreased nonsteroidal anti-inflammatory drug prescribing and increased renal function Kidney International (84)1 174-178
chronic kidney disease in primary care
CKD as a Public Health Issue
Slide Number 3
Costs of CKD in 2013 dollarsUSRDS report
Steps to CKD Patient Care
Renal anatomy and physiology
Definition of Chronic Kidney Disease
CKD Risk Factors
Gaps in CKD Diagnosis
Slide Number 10
Steps to CKD Patient Care
creatinine
Glomerular filtration rate
Slide Number 14
Slide Number 15
Use These Equations Cautiously if at all in hellip
lab albumin creatinine ratio
The New CKD Categories
Steps to CKD Patient Care
Slide Number 20
Kidney Involvement in Systemic Diseases
Slide Number 22
Slide Number 23
DysmorphicRenal Hematuria
Slide Number 25
If you have albuminuria or hematuria-order the following labs
bull Progression of disease ndash declining eGFR increasing proteinuria
bull Degree of proteinuria nephrotic syndrome gt 05-10 gd on ACEi or ARB therapy
bull Etiology of CKD not certain
bull Need help with disease management
bull Indications for kidney biopsy
Rosenberg 2016
WHEN TO REFER
STEPS TO CKD PATIENT CARE
1 CKD definition and risks2 Assess GFR albuminuria3 Determine etiology4 Assess for evidence of progression5 Assess for associated complications6 Discuss dialysistransplantation
KIDNEY TRANSPLANTATION
bull Treatment of choice for ESRDbull Improves quality of lifebull Waiting list time varies-3-5 yearsbull 3 year survival rate after transplantation is 83-94bull Increased risk of cancer
STARTING DIALYSIS IN THE ELDERLYhellipOR NOT
bull Among patients gt 75 yrs with stage 5 CKD who chose to NOT start dialysisbull Overall more likely to die over next 1-2 years bull But if they had ischemic heart disease or other significant comorbidity NO
DIFFERENCE in survival
bull Active disease management and supportive care may be appropriate without starting dialysis in the ill elderly
bull Palliative care does not mean ldquono carerdquo
bull Must have end-of-life discussions
(Murtagh et al 2007)
CKD MANAGEMENTbull Diagnose cause and treat underlying conditionbull Stage per guidelinesbull Slow progression of kidney disease (ACE inhibitors)bull Monitor for complicationsmdashvolume overload hyperkalemia metabolic acidosis
hyperphosphatemia anorexia fatigue htn bone diseasebull Labs cmp cbc phos Vit D 25OH iPTH urine microscopy uric acid urine
proteincr ratio-frequency based off heat map Get sono at least oncebull Vaccinate influenza hep B pneumococcalbull Eval ASCVD risk-likely needs statinbull Possible dexa (donrsquot give bisphosphonates if GFRlt35 let specialist manage)bull Refer to nephrology when eGFR is lt30 (sometimes if higher risk-refer earlier)
CASE 1
bull 55 year old man with past medical history of headaches presents to your office for his first time visit to a PCP in over 30 years
bull He has no past history of being admitted to the hospital and he does not take any OTC medsNSAIDsherbal meds He has no history of ETOH abuse smoking or drug use
bull Vitals BP 180100 mmHg pulse 80 R 18
bull Exam No JVD S1S2 regular PMI shifted to the left no gallop no abdominal bruit pulses bilaterally equal and regular no leg edema
bull What would you order
bull EKG cbc cmp ua urine proteincr ratio lipid
LAB RESULTS
bull Labs reveal a creatinine of 22 mgdL eGFR 33 Urine shows no blood or casts Urineprotein ratio shows 1 gm protein24 hrs EKG shows LVH
bull Next step in workupbull Renal ultrasound 1st then SPEP UPEP with immunofixation serum free light chains
bull Additional labs neg Renal ultrasound shows that both kidneys are slightly reduced in size and are mildly echogenic with no mass or hydronephrosis
bull What is your diagnosis
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileMain_complications_of_persistent_high_blood_pressurepngCreative Commons License associated httpcreativecommonsorglicensesby-sa30
bull 3 months Howevermdashwe have evidence of structural abnormalities Could potentially stage at G3b A3 (red on the heat map)
bull Goal blood pressure
bull JNC 8 14090 NKF 13080
bull Additional lab needed for progression monitoring
bull Cbc renal panel phos Vit D iPTH uric acid urine micro (we already have the renal sono and urine proteincr ratio and lipid)
Selective renal angiography (left lower renal artery) after successful percutaneous balloon dilatation of the stenotic lesionFibromuscular dysplasia in an accessory renal artery causing renovascular hypertension
Secondary Hypertension
Images retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileRenal_FMD2jpg and httpcommonswikimediaorgwikiFileRenal_FMDjpgCreative Commons License associated httpcreativecommonsorglicensesby20deeden (both images)
CASE 2bull OS is a 64year old Hispanic female in for DM check She has had DM for 15+ years and is currently
taking metformin 1000mg bid Lisinopril 10mg a day atorvastatin 40mg a day Labs today showed the following
bull Hgba1c 86 cmp eGFR 50 lipid WNL proteincr ratio 650mg These results are similar to her last visit
bull Upon further hx-you find that she had a recent eye exam and has mild nonproliferaive retinopathy She does not have neuropathy or other ss
bull What further workup do you need
bull Renal sonogram urine micro iPTH vit D (25 OH) phos uric acid
bull Dx stage
bull G3a A3
bull What further treatment do you need
bull Improve glycemic control Increase Lisinopril to 20mg with a goal of 40mg Avoid NSAIDs or other nephrotoxic agents make sure meds are renally dosed monitor 3xyear nephro referral
MANAGEMENT OF CKD IN DIABETESeGFR Recommended
All patients
Yearly measurement of creatinine urinary albumin excretion potassium
45-60 Referral to a nephrologist if possibility for nondiabetickidney disease existsConsider dose adjustment of medicationsMonitor eGFR every 6 monthsMonitor electrolytes bicarbonate hemoglobin calcium phosphorus parathyroid hormone at least yearly
Assure vitamin D sufficiencyConsider bone density testingReferral for dietary counselling
American Diabetes Association Standards of Medical Care in Diabetes Microvascular complications and foot care Diabetes Care 2017 40 (Suppl 1) S88-S98
CASE 3
bull 19 year old African American woman presents to your clinic with complaints of fatigue joint pains a new rash on her face oral ulcer
bull On exam BP 15080 P 88 Afebrile 96 O2 sats on RAbull GEN No respiratory distress at restbull HEENT painless oral ulcer flat rash over malar eminences sparing the nasolabial fold pallor +bull Lungs CTAbull CVS S1S2 regularbull Abdomen soft NTbull Ext left elbow joint and bilateral wrist joints are swollen and tender
bull What would you orderbull CBC CMP ua urine microscopy (microalbumin or urine proteincr ratio) ANA esr RF anti-ccp uric acid TSH
CASE 3
bull Working dx fatigue oral ulcer joint pain
bull Basic Labs Na 135 K 55 Bicarb 18 BUN 50 Cr 35 eGFR 22 Ca 90 ANA + titer 1640
bull UA 3+ blood 3+ protein RBC casts +
bull Given these results what is the most likely diagnosis
bull What would you do
SYSTEMIC LUPUS ERYTHEMATOSUS (SLE)
bull SLE multisystemic disease Etiology unknown
bull Production of autoantibodies and immune complexes formation
bull There is renal involvement in the great majority of patients with SLE at some time of the evolution 66-90
SLE ndash LUPUS NEPHRITIS
bull Race SLE is more commonsevere in African americans than Caucasiansbull
bull Gender female-to-male ratio of 91
bull Age Most patients develop lupus nephritis early in their disease course SLE is more common among women in the third decade of life and lupus nephritis occurs in patients aged 20-40 years
bull Kidney Biopsy For staging lupus nephritis (Class 1-5)
CASE 5bull A 80 year old man who has not seen a PCP in many years
presents to your clinic for weakness for the past few months On further questioning he tells you that his bones also have been hurting lately and he has developed leg swelling in the past month or so
bull On exam bull BP 16090 P 88 Afebrilebull GEN Thin built manbull HEENT pallor presentbull Lungs clearbull CVS S1S2 regular no rub or gallopbull Abdomen soft NTbull Ext 2 + edema
CASE 5
bull Differentials
bull CHF MI Cancer arthritis
bull Labs
bull CBC CMP urine microscopy urine proteincr ratio ESR TSH EKG BNP pa and lat CXR
bull LABS Urine dipstick negative for protein or blood
bull Basic chem bull Na 136 (135-145) K 51 (35-55) Chloride 108 (96-106) Bicarb 25
Given this presentation and the labs (low anion gap and elevated calcium anemia kidney failure) what will you think of What will you order next
Serum and urine protein electrophoresis
Intratubular refractile casts with surrounding syncytial giant cell reaction with chronic tubulointerstitial nephritis and fibrosis characteristic of myeloma cast nephropathy
Kidney Biopsy
CASE STUDYbull A 35 year old African American woman was seen in the clinic for
chronic cough and dyspnea on exertion She gave history of vague symptoms of fatigue and weight loss of 20 Ibs over the last six months
bull List some differentialsbull TB sarcoid lupus thyroid problems PEbull What would you orderbull PPD cbc cmp UA TSH ANA pa and lat cxr
bull Her labs were significant for mildly elevated calcium level and a creatinine of 20 mgdL eGFR 37
bull She had 750 mg of proteinuriaday
bull PPD neg ANA neg TSH and other labs WNL
bull Assuming this is present more than 3 monthshelliphellipwhat is her ckd stage
bull G3b A3
bull What do we still need
CT scan of chest
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileAnterior_mediastinal_mass_thymomajpgCreative Commons License associated httpcreativecommonsorglicensesby20deeden
CXR ndash HILAR LYMPHADENOPATHY
WHATS NEEDED NEXT
bull Biopsy of hilar lymphadenopathy or renal biopsy
bull DX sarcoidosis
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileSarcoidosis_signs_and_symptomsjpgThis work is in the public domain in the United States because it is a work of the United States Federal Government under the terms of Title 17 Chapter 1 Section 105 of the US Code
NEWLY DX CKD
bull 1) urinalysis microscopy ultrasound proteincr ratio
bull If obstruction-treat
bull No obstruction
bull Hx critical (consider myeloma if high risk)
bull glomerular bleeding or albumin in urine
bull Yes workup for glomerular causes (ANArf hep B C upep spep ANCA complement C3 C4)
bull No sterile pyruria-consider interstitial nephritis
bull High risk renovascular disease Evaluate renovascular disease
Additional Online Resources for CKD LearningbullNational Kidney Foundation wwwkidneyorgbullUnited States Renal Data Service wwwusrdsorgbullCDCrsquos CKD Surveillance Project
httpnccdcdcgovckdbullNational Kidney Disease Education Program
(NKDEP) httpnkdepnihgov
BIBLIOGRAPHY
bull Afzali B amp Goldsmith D J (2016 June 29) Statins and chronic kidney disease (G C Curhan amp A M Sheridan Eds) Retrieved 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsstatins-and-chronic-kidney-disease
bull American Diabetes Association Standards of Medical Care in Diabetes (2017) Microvascular complications and foot care Diabetes Care 2017 (40) S88-S98
bull American Diabetes Association Standards of Medical Care in Diabetes (2017) Microvascular complications and foot care Diabetes Care 40 (suppl 1) S88-S98
bull Berns J S (2017 Mar 22) Treatment of anemia in nondialysis chronic kidney disease (T A Golper amp A M Sheridan Eds) Retrieved from UpToDate httpswww-uptodate-comproxywichitaeducontentstreatment-of-anemia-in-nondialysis-chronic-kidney-disease
bull Chan M Dall A T Fletcher K E Lu N amp Trivedi H (2007) Outcomes in patients with chronic kidney disease referred late to nephrologists a meta-analysis American Journal of Medicine 120(12) 1063-1070
bull Coresh J Selvin E amp Stevens L A (2007) Prevalence of chronic kidny disease in the United States JAMA 298(17) doi101001jama298172038
bull de Brito-Ashurst I Varagunam M Raftery M amp Yagoob M (2009) Bicarbonate supplementation slows progression of CKD and improves nutritional status Journal of American Society of Nephrology (20) 2075-2084
BIBLIOGRAPHY
bull Duncan L Heathcoat J Djurdjev O amp Levin A (2001) Screening for renal disease using serum creatinine who are we missing Nephrology Dialysis and Transplant 16(5) 1042-1046
bull Dunkler D Gao P Lee S F Heinz G Clase C M Tobe S Oberbauer R (2015 August 7) Risk prediction for early CKD in type 2 diabetes Retrieved from Clinical Journal of the American Society of Nephrology httpcjasnasnjournalsorgcontent1081371fullsid=61422554-a5f1-41ac-b696-dcd3b12bd268
bull Fatehi P amp Chi-yuan H (September 15 2016) Diagnostic approach to the patient with newly identified chronic kidney disease (G C Curhan amp A M Sheridan Eds) Retrieved May 7 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsdiagnostic-approach-to-the-patient-with-newly-identified-chronic-kidney-disease
bull Fink J e (2009) Chronic Kidney Disease as an Under-Recognized Threat to Patient Safety American journal of kidney diseases the official journal of the National Kidney Foundation 53(4) 681-688
bull Gaffo A L amp Saag K G (2008 Nov) Management of hyperuricemia and gout in CKD doihttpdxdoiorg101053jajkd200807035
bull Hebert L A amp Parikh S V (2014 June 18) Differential diagnosis and evaluation of glomerular disease (R J Glassock amp A Q Lam Eds) Retrieved May 7 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsdifferential-diagnosis-and-evaluation-of-glomerular-disease
bull Inker L Perrone R D Sterns R H amp Forman J P (2017 March 7) Assessment of kidney function Retrieved from UpToDate httpswww-uptodate-comproxywichitaeducontentsassessment-of-kidney-functionsource=search_resultampsearch=creatinineampselectedTitle=1~150
BIBLIOGRAPHY
bull James P A Ortiz E amp Et Al (2014) Evidence based guideline for the management of high blood pressure in adults (JNC) JAMA 311(5) 507-520
bull Kidney Disease Improving Global Outcomes (KDIGO) CKD Work Group (2013 January) KDIGO 2012 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease Retrieved from Kidney International Supplement httpwwwkidney-internationalorg
bull Kunz R Friedrich C Wolbers M amp Mann J F (2008) Meta-analysis effect of monotherapy and combination therapy with inhibitors of the renin angiotensin system on proteinuria in renal disease Annals of Internal Medicine 148(1) 30-48
bull Levey A Stevens L A Schmid C H Castro A F Feldman H I Kusek J W Coresh J (2009) A new equation to estimate glomerular filtration rate Annals of Internal Medicine 150(9) 604-612
bull Levin A Bakris G L Molitch M Smulders M M Williams L A amp Andress D L (2007 Jan) Prevalence of abnormal serum vitamin D PTH calcium and phosphorus in patients with chronic kidney disease results of the study to evaluate early kidney disease Kidney International 71(1) 31-38 Retrieved from PubMED
bull Mahajan A Simoni J Sheather S Broglio K Rajab M amp Wesson D (2010) Daily oral sodium bicarbonate preserves glomerular filtration rate by slowing its decline in early hypertensive nephropathy Kidney International (78_ 303-309
bull Mann J Schmieder R E amp McQueen M (2008) Renal outcomes with telmisartan ramipril or both in people at high vascular risk (the ONTARGET study) a multicentre randomised doubleblind ocntrolled trial Lancet 372(9638) 547-533
BIBLIOGRAPHY
bull Matovinović M S (2009) Pathophysiology and classification of kidney disease Retrieved from The Journal of the International Federation of Clinical Chemistry and Laboratory Medicine httpwwwifccorgifccfilesdocs20010902pdf
bull Moe S Drueke T Lameire N amp Eknoyan G (2007 Jan) Chronic kidney disease-mineral-bone disorder a new paradigmdoi101053jackd200610005
bull Murtagh F E Marsh J E Donohoe P Ekbal N J Sheerin N S amp Harris F E (2007 July) Dialysis or not A comparative survival study of patients over 75 years with chronic kidney disease stage 5 Retrieved from Nephrology Dialysis and Transplant 22(7) httpswwwncbinlmnihgovpubmed17412702
bull National Kidney Foundation (2002) KDOQI clinical practice guidelines for chronic kidney disease evaluation classification andstratification American Journal of Kidney Disease S1-S266
bull National Kidney Foundation (2014 November 5) Fact Sheets Retrieved from httpwwwkidneyorgnewsnewsroomfactsheetsFastFacts
bull Pal S (2012 June 2) Trends in chronic kidney disease Retrieved from US Pharmacist (37)6 httpswwwuspharmacistcomarticletrends-in-chronic-kidney-disease
bull Qunibi W amp Henrich W L (2017 Jan 19) Overview of chronic kidney disease-mineral and bone disorder (J Berns amp A M Sheridan Eds) Retrieved from UpToDate httpswww-uptodate-comoverview-of-chronic-kidney-disease-mineral-and-bone-disorder-ckd-mbd
bull Rosenberg M (2016 Feb 24) Overview of the management of chronic kidney disease in adults (G C Curhan amp A M Sheridan Eds) Retrieved from UpToDate UpToDate httpswww-uptodate-comproxywichitaeducontentsoverview-of-the-management-of-chronic-kidney-disease-in-adults
BIBLIOGRAPHY
bull Szczech L Stewart R C Hsu-Lin S DeLosky R J Astor B C Fox C H Vassalotti J A (2014) Primary care detection of chronic kidney disease in adults with type 2 diabetes The ADD-CKD Study (Awareness Detection and Drug Therapy in type 2 diabetes and chronic kidney disease PLOS doihttpsdoiorg101371journalpone0110535
bull USRDS (2016) Annual data report 2016 Epidemiology of kidney disease in the United States Retrieved from United States Renal Data System httpswwwusrdsorgadraspx
bull Vasudev B amp Vasudev M (2012) A model curriculum for residents rotating in nephrology MedEDPORTAL doihttpdoiorg1015766mep_2374-82658288
bull Wei L MacDonald T M Jennings C Sheng X amp Flynn R W (2013) Estimated GFR reporting is associated with decreased nonsteroidal anti-inflammatory drug prescribing and increased renal function Kidney International (84)1 174-178
chronic kidney disease in primary care
CKD as a Public Health Issue
Slide Number 3
Costs of CKD in 2013 dollarsUSRDS report
Steps to CKD Patient Care
Renal anatomy and physiology
Definition of Chronic Kidney Disease
CKD Risk Factors
Gaps in CKD Diagnosis
Slide Number 10
Steps to CKD Patient Care
creatinine
Glomerular filtration rate
Slide Number 14
Slide Number 15
Use These Equations Cautiously if at all in hellip
lab albumin creatinine ratio
The New CKD Categories
Steps to CKD Patient Care
Slide Number 20
Kidney Involvement in Systemic Diseases
Slide Number 22
Slide Number 23
DysmorphicRenal Hematuria
Slide Number 25
If you have albuminuria or hematuria-order the following labs
bull Progression of disease ndash declining eGFR increasing proteinuria
bull Degree of proteinuria nephrotic syndrome gt 05-10 gd on ACEi or ARB therapy
bull Etiology of CKD not certain
bull Need help with disease management
bull Indications for kidney biopsy
Rosenberg 2016
WHEN TO REFER
STEPS TO CKD PATIENT CARE
1 CKD definition and risks2 Assess GFR albuminuria3 Determine etiology4 Assess for evidence of progression5 Assess for associated complications6 Discuss dialysistransplantation
KIDNEY TRANSPLANTATION
bull Treatment of choice for ESRDbull Improves quality of lifebull Waiting list time varies-3-5 yearsbull 3 year survival rate after transplantation is 83-94bull Increased risk of cancer
STARTING DIALYSIS IN THE ELDERLYhellipOR NOT
bull Among patients gt 75 yrs with stage 5 CKD who chose to NOT start dialysisbull Overall more likely to die over next 1-2 years bull But if they had ischemic heart disease or other significant comorbidity NO
DIFFERENCE in survival
bull Active disease management and supportive care may be appropriate without starting dialysis in the ill elderly
bull Palliative care does not mean ldquono carerdquo
bull Must have end-of-life discussions
(Murtagh et al 2007)
CKD MANAGEMENTbull Diagnose cause and treat underlying conditionbull Stage per guidelinesbull Slow progression of kidney disease (ACE inhibitors)bull Monitor for complicationsmdashvolume overload hyperkalemia metabolic acidosis
hyperphosphatemia anorexia fatigue htn bone diseasebull Labs cmp cbc phos Vit D 25OH iPTH urine microscopy uric acid urine
proteincr ratio-frequency based off heat map Get sono at least oncebull Vaccinate influenza hep B pneumococcalbull Eval ASCVD risk-likely needs statinbull Possible dexa (donrsquot give bisphosphonates if GFRlt35 let specialist manage)bull Refer to nephrology when eGFR is lt30 (sometimes if higher risk-refer earlier)
CASE 1
bull 55 year old man with past medical history of headaches presents to your office for his first time visit to a PCP in over 30 years
bull He has no past history of being admitted to the hospital and he does not take any OTC medsNSAIDsherbal meds He has no history of ETOH abuse smoking or drug use
bull Vitals BP 180100 mmHg pulse 80 R 18
bull Exam No JVD S1S2 regular PMI shifted to the left no gallop no abdominal bruit pulses bilaterally equal and regular no leg edema
bull What would you order
bull EKG cbc cmp ua urine proteincr ratio lipid
LAB RESULTS
bull Labs reveal a creatinine of 22 mgdL eGFR 33 Urine shows no blood or casts Urineprotein ratio shows 1 gm protein24 hrs EKG shows LVH
bull Next step in workupbull Renal ultrasound 1st then SPEP UPEP with immunofixation serum free light chains
bull Additional labs neg Renal ultrasound shows that both kidneys are slightly reduced in size and are mildly echogenic with no mass or hydronephrosis
bull What is your diagnosis
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileMain_complications_of_persistent_high_blood_pressurepngCreative Commons License associated httpcreativecommonsorglicensesby-sa30
bull 3 months Howevermdashwe have evidence of structural abnormalities Could potentially stage at G3b A3 (red on the heat map)
bull Goal blood pressure
bull JNC 8 14090 NKF 13080
bull Additional lab needed for progression monitoring
bull Cbc renal panel phos Vit D iPTH uric acid urine micro (we already have the renal sono and urine proteincr ratio and lipid)
Selective renal angiography (left lower renal artery) after successful percutaneous balloon dilatation of the stenotic lesionFibromuscular dysplasia in an accessory renal artery causing renovascular hypertension
Secondary Hypertension
Images retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileRenal_FMD2jpg and httpcommonswikimediaorgwikiFileRenal_FMDjpgCreative Commons License associated httpcreativecommonsorglicensesby20deeden (both images)
CASE 2bull OS is a 64year old Hispanic female in for DM check She has had DM for 15+ years and is currently
taking metformin 1000mg bid Lisinopril 10mg a day atorvastatin 40mg a day Labs today showed the following
bull Hgba1c 86 cmp eGFR 50 lipid WNL proteincr ratio 650mg These results are similar to her last visit
bull Upon further hx-you find that she had a recent eye exam and has mild nonproliferaive retinopathy She does not have neuropathy or other ss
bull What further workup do you need
bull Renal sonogram urine micro iPTH vit D (25 OH) phos uric acid
bull Dx stage
bull G3a A3
bull What further treatment do you need
bull Improve glycemic control Increase Lisinopril to 20mg with a goal of 40mg Avoid NSAIDs or other nephrotoxic agents make sure meds are renally dosed monitor 3xyear nephro referral
MANAGEMENT OF CKD IN DIABETESeGFR Recommended
All patients
Yearly measurement of creatinine urinary albumin excretion potassium
45-60 Referral to a nephrologist if possibility for nondiabetickidney disease existsConsider dose adjustment of medicationsMonitor eGFR every 6 monthsMonitor electrolytes bicarbonate hemoglobin calcium phosphorus parathyroid hormone at least yearly
Assure vitamin D sufficiencyConsider bone density testingReferral for dietary counselling
American Diabetes Association Standards of Medical Care in Diabetes Microvascular complications and foot care Diabetes Care 2017 40 (Suppl 1) S88-S98
CASE 3
bull 19 year old African American woman presents to your clinic with complaints of fatigue joint pains a new rash on her face oral ulcer
bull On exam BP 15080 P 88 Afebrile 96 O2 sats on RAbull GEN No respiratory distress at restbull HEENT painless oral ulcer flat rash over malar eminences sparing the nasolabial fold pallor +bull Lungs CTAbull CVS S1S2 regularbull Abdomen soft NTbull Ext left elbow joint and bilateral wrist joints are swollen and tender
bull What would you orderbull CBC CMP ua urine microscopy (microalbumin or urine proteincr ratio) ANA esr RF anti-ccp uric acid TSH
CASE 3
bull Working dx fatigue oral ulcer joint pain
bull Basic Labs Na 135 K 55 Bicarb 18 BUN 50 Cr 35 eGFR 22 Ca 90 ANA + titer 1640
bull UA 3+ blood 3+ protein RBC casts +
bull Given these results what is the most likely diagnosis
bull What would you do
SYSTEMIC LUPUS ERYTHEMATOSUS (SLE)
bull SLE multisystemic disease Etiology unknown
bull Production of autoantibodies and immune complexes formation
bull There is renal involvement in the great majority of patients with SLE at some time of the evolution 66-90
SLE ndash LUPUS NEPHRITIS
bull Race SLE is more commonsevere in African americans than Caucasiansbull
bull Gender female-to-male ratio of 91
bull Age Most patients develop lupus nephritis early in their disease course SLE is more common among women in the third decade of life and lupus nephritis occurs in patients aged 20-40 years
bull Kidney Biopsy For staging lupus nephritis (Class 1-5)
CASE 5bull A 80 year old man who has not seen a PCP in many years
presents to your clinic for weakness for the past few months On further questioning he tells you that his bones also have been hurting lately and he has developed leg swelling in the past month or so
bull On exam bull BP 16090 P 88 Afebrilebull GEN Thin built manbull HEENT pallor presentbull Lungs clearbull CVS S1S2 regular no rub or gallopbull Abdomen soft NTbull Ext 2 + edema
CASE 5
bull Differentials
bull CHF MI Cancer arthritis
bull Labs
bull CBC CMP urine microscopy urine proteincr ratio ESR TSH EKG BNP pa and lat CXR
bull LABS Urine dipstick negative for protein or blood
bull Basic chem bull Na 136 (135-145) K 51 (35-55) Chloride 108 (96-106) Bicarb 25
Given this presentation and the labs (low anion gap and elevated calcium anemia kidney failure) what will you think of What will you order next
Serum and urine protein electrophoresis
Intratubular refractile casts with surrounding syncytial giant cell reaction with chronic tubulointerstitial nephritis and fibrosis characteristic of myeloma cast nephropathy
Kidney Biopsy
CASE STUDYbull A 35 year old African American woman was seen in the clinic for
chronic cough and dyspnea on exertion She gave history of vague symptoms of fatigue and weight loss of 20 Ibs over the last six months
bull List some differentialsbull TB sarcoid lupus thyroid problems PEbull What would you orderbull PPD cbc cmp UA TSH ANA pa and lat cxr
bull Her labs were significant for mildly elevated calcium level and a creatinine of 20 mgdL eGFR 37
bull She had 750 mg of proteinuriaday
bull PPD neg ANA neg TSH and other labs WNL
bull Assuming this is present more than 3 monthshelliphellipwhat is her ckd stage
bull G3b A3
bull What do we still need
CT scan of chest
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileAnterior_mediastinal_mass_thymomajpgCreative Commons License associated httpcreativecommonsorglicensesby20deeden
CXR ndash HILAR LYMPHADENOPATHY
WHATS NEEDED NEXT
bull Biopsy of hilar lymphadenopathy or renal biopsy
bull DX sarcoidosis
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileSarcoidosis_signs_and_symptomsjpgThis work is in the public domain in the United States because it is a work of the United States Federal Government under the terms of Title 17 Chapter 1 Section 105 of the US Code
NEWLY DX CKD
bull 1) urinalysis microscopy ultrasound proteincr ratio
bull If obstruction-treat
bull No obstruction
bull Hx critical (consider myeloma if high risk)
bull glomerular bleeding or albumin in urine
bull Yes workup for glomerular causes (ANArf hep B C upep spep ANCA complement C3 C4)
bull No sterile pyruria-consider interstitial nephritis
bull High risk renovascular disease Evaluate renovascular disease
Additional Online Resources for CKD LearningbullNational Kidney Foundation wwwkidneyorgbullUnited States Renal Data Service wwwusrdsorgbullCDCrsquos CKD Surveillance Project
httpnccdcdcgovckdbullNational Kidney Disease Education Program
(NKDEP) httpnkdepnihgov
BIBLIOGRAPHY
bull Afzali B amp Goldsmith D J (2016 June 29) Statins and chronic kidney disease (G C Curhan amp A M Sheridan Eds) Retrieved 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsstatins-and-chronic-kidney-disease
bull American Diabetes Association Standards of Medical Care in Diabetes (2017) Microvascular complications and foot care Diabetes Care 2017 (40) S88-S98
bull American Diabetes Association Standards of Medical Care in Diabetes (2017) Microvascular complications and foot care Diabetes Care 40 (suppl 1) S88-S98
bull Berns J S (2017 Mar 22) Treatment of anemia in nondialysis chronic kidney disease (T A Golper amp A M Sheridan Eds) Retrieved from UpToDate httpswww-uptodate-comproxywichitaeducontentstreatment-of-anemia-in-nondialysis-chronic-kidney-disease
bull Chan M Dall A T Fletcher K E Lu N amp Trivedi H (2007) Outcomes in patients with chronic kidney disease referred late to nephrologists a meta-analysis American Journal of Medicine 120(12) 1063-1070
bull Coresh J Selvin E amp Stevens L A (2007) Prevalence of chronic kidny disease in the United States JAMA 298(17) doi101001jama298172038
bull de Brito-Ashurst I Varagunam M Raftery M amp Yagoob M (2009) Bicarbonate supplementation slows progression of CKD and improves nutritional status Journal of American Society of Nephrology (20) 2075-2084
BIBLIOGRAPHY
bull Duncan L Heathcoat J Djurdjev O amp Levin A (2001) Screening for renal disease using serum creatinine who are we missing Nephrology Dialysis and Transplant 16(5) 1042-1046
bull Dunkler D Gao P Lee S F Heinz G Clase C M Tobe S Oberbauer R (2015 August 7) Risk prediction for early CKD in type 2 diabetes Retrieved from Clinical Journal of the American Society of Nephrology httpcjasnasnjournalsorgcontent1081371fullsid=61422554-a5f1-41ac-b696-dcd3b12bd268
bull Fatehi P amp Chi-yuan H (September 15 2016) Diagnostic approach to the patient with newly identified chronic kidney disease (G C Curhan amp A M Sheridan Eds) Retrieved May 7 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsdiagnostic-approach-to-the-patient-with-newly-identified-chronic-kidney-disease
bull Fink J e (2009) Chronic Kidney Disease as an Under-Recognized Threat to Patient Safety American journal of kidney diseases the official journal of the National Kidney Foundation 53(4) 681-688
bull Gaffo A L amp Saag K G (2008 Nov) Management of hyperuricemia and gout in CKD doihttpdxdoiorg101053jajkd200807035
bull Hebert L A amp Parikh S V (2014 June 18) Differential diagnosis and evaluation of glomerular disease (R J Glassock amp A Q Lam Eds) Retrieved May 7 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsdifferential-diagnosis-and-evaluation-of-glomerular-disease
bull Inker L Perrone R D Sterns R H amp Forman J P (2017 March 7) Assessment of kidney function Retrieved from UpToDate httpswww-uptodate-comproxywichitaeducontentsassessment-of-kidney-functionsource=search_resultampsearch=creatinineampselectedTitle=1~150
BIBLIOGRAPHY
bull James P A Ortiz E amp Et Al (2014) Evidence based guideline for the management of high blood pressure in adults (JNC) JAMA 311(5) 507-520
bull Kidney Disease Improving Global Outcomes (KDIGO) CKD Work Group (2013 January) KDIGO 2012 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease Retrieved from Kidney International Supplement httpwwwkidney-internationalorg
bull Kunz R Friedrich C Wolbers M amp Mann J F (2008) Meta-analysis effect of monotherapy and combination therapy with inhibitors of the renin angiotensin system on proteinuria in renal disease Annals of Internal Medicine 148(1) 30-48
bull Levey A Stevens L A Schmid C H Castro A F Feldman H I Kusek J W Coresh J (2009) A new equation to estimate glomerular filtration rate Annals of Internal Medicine 150(9) 604-612
bull Levin A Bakris G L Molitch M Smulders M M Williams L A amp Andress D L (2007 Jan) Prevalence of abnormal serum vitamin D PTH calcium and phosphorus in patients with chronic kidney disease results of the study to evaluate early kidney disease Kidney International 71(1) 31-38 Retrieved from PubMED
bull Mahajan A Simoni J Sheather S Broglio K Rajab M amp Wesson D (2010) Daily oral sodium bicarbonate preserves glomerular filtration rate by slowing its decline in early hypertensive nephropathy Kidney International (78_ 303-309
bull Mann J Schmieder R E amp McQueen M (2008) Renal outcomes with telmisartan ramipril or both in people at high vascular risk (the ONTARGET study) a multicentre randomised doubleblind ocntrolled trial Lancet 372(9638) 547-533
BIBLIOGRAPHY
bull Matovinović M S (2009) Pathophysiology and classification of kidney disease Retrieved from The Journal of the International Federation of Clinical Chemistry and Laboratory Medicine httpwwwifccorgifccfilesdocs20010902pdf
bull Moe S Drueke T Lameire N amp Eknoyan G (2007 Jan) Chronic kidney disease-mineral-bone disorder a new paradigmdoi101053jackd200610005
bull Murtagh F E Marsh J E Donohoe P Ekbal N J Sheerin N S amp Harris F E (2007 July) Dialysis or not A comparative survival study of patients over 75 years with chronic kidney disease stage 5 Retrieved from Nephrology Dialysis and Transplant 22(7) httpswwwncbinlmnihgovpubmed17412702
bull National Kidney Foundation (2002) KDOQI clinical practice guidelines for chronic kidney disease evaluation classification andstratification American Journal of Kidney Disease S1-S266
bull National Kidney Foundation (2014 November 5) Fact Sheets Retrieved from httpwwwkidneyorgnewsnewsroomfactsheetsFastFacts
bull Pal S (2012 June 2) Trends in chronic kidney disease Retrieved from US Pharmacist (37)6 httpswwwuspharmacistcomarticletrends-in-chronic-kidney-disease
bull Qunibi W amp Henrich W L (2017 Jan 19) Overview of chronic kidney disease-mineral and bone disorder (J Berns amp A M Sheridan Eds) Retrieved from UpToDate httpswww-uptodate-comoverview-of-chronic-kidney-disease-mineral-and-bone-disorder-ckd-mbd
bull Rosenberg M (2016 Feb 24) Overview of the management of chronic kidney disease in adults (G C Curhan amp A M Sheridan Eds) Retrieved from UpToDate UpToDate httpswww-uptodate-comproxywichitaeducontentsoverview-of-the-management-of-chronic-kidney-disease-in-adults
BIBLIOGRAPHY
bull Szczech L Stewart R C Hsu-Lin S DeLosky R J Astor B C Fox C H Vassalotti J A (2014) Primary care detection of chronic kidney disease in adults with type 2 diabetes The ADD-CKD Study (Awareness Detection and Drug Therapy in type 2 diabetes and chronic kidney disease PLOS doihttpsdoiorg101371journalpone0110535
bull USRDS (2016) Annual data report 2016 Epidemiology of kidney disease in the United States Retrieved from United States Renal Data System httpswwwusrdsorgadraspx
bull Vasudev B amp Vasudev M (2012) A model curriculum for residents rotating in nephrology MedEDPORTAL doihttpdoiorg1015766mep_2374-82658288
bull Wei L MacDonald T M Jennings C Sheng X amp Flynn R W (2013) Estimated GFR reporting is associated with decreased nonsteroidal anti-inflammatory drug prescribing and increased renal function Kidney International (84)1 174-178
chronic kidney disease in primary care
CKD as a Public Health Issue
Slide Number 3
Costs of CKD in 2013 dollarsUSRDS report
Steps to CKD Patient Care
Renal anatomy and physiology
Definition of Chronic Kidney Disease
CKD Risk Factors
Gaps in CKD Diagnosis
Slide Number 10
Steps to CKD Patient Care
creatinine
Glomerular filtration rate
Slide Number 14
Slide Number 15
Use These Equations Cautiously if at all in hellip
lab albumin creatinine ratio
The New CKD Categories
Steps to CKD Patient Care
Slide Number 20
Kidney Involvement in Systemic Diseases
Slide Number 22
Slide Number 23
DysmorphicRenal Hematuria
Slide Number 25
If you have albuminuria or hematuria-order the following labs
bull Progression of disease ndash declining eGFR increasing proteinuria
bull Degree of proteinuria nephrotic syndrome gt 05-10 gd on ACEi or ARB therapy
bull Etiology of CKD not certain
bull Need help with disease management
bull Indications for kidney biopsy
Rosenberg 2016
WHEN TO REFER
STEPS TO CKD PATIENT CARE
1 CKD definition and risks2 Assess GFR albuminuria3 Determine etiology4 Assess for evidence of progression5 Assess for associated complications6 Discuss dialysistransplantation
KIDNEY TRANSPLANTATION
bull Treatment of choice for ESRDbull Improves quality of lifebull Waiting list time varies-3-5 yearsbull 3 year survival rate after transplantation is 83-94bull Increased risk of cancer
STARTING DIALYSIS IN THE ELDERLYhellipOR NOT
bull Among patients gt 75 yrs with stage 5 CKD who chose to NOT start dialysisbull Overall more likely to die over next 1-2 years bull But if they had ischemic heart disease or other significant comorbidity NO
DIFFERENCE in survival
bull Active disease management and supportive care may be appropriate without starting dialysis in the ill elderly
bull Palliative care does not mean ldquono carerdquo
bull Must have end-of-life discussions
(Murtagh et al 2007)
CKD MANAGEMENTbull Diagnose cause and treat underlying conditionbull Stage per guidelinesbull Slow progression of kidney disease (ACE inhibitors)bull Monitor for complicationsmdashvolume overload hyperkalemia metabolic acidosis
hyperphosphatemia anorexia fatigue htn bone diseasebull Labs cmp cbc phos Vit D 25OH iPTH urine microscopy uric acid urine
proteincr ratio-frequency based off heat map Get sono at least oncebull Vaccinate influenza hep B pneumococcalbull Eval ASCVD risk-likely needs statinbull Possible dexa (donrsquot give bisphosphonates if GFRlt35 let specialist manage)bull Refer to nephrology when eGFR is lt30 (sometimes if higher risk-refer earlier)
CASE 1
bull 55 year old man with past medical history of headaches presents to your office for his first time visit to a PCP in over 30 years
bull He has no past history of being admitted to the hospital and he does not take any OTC medsNSAIDsherbal meds He has no history of ETOH abuse smoking or drug use
bull Vitals BP 180100 mmHg pulse 80 R 18
bull Exam No JVD S1S2 regular PMI shifted to the left no gallop no abdominal bruit pulses bilaterally equal and regular no leg edema
bull What would you order
bull EKG cbc cmp ua urine proteincr ratio lipid
LAB RESULTS
bull Labs reveal a creatinine of 22 mgdL eGFR 33 Urine shows no blood or casts Urineprotein ratio shows 1 gm protein24 hrs EKG shows LVH
bull Next step in workupbull Renal ultrasound 1st then SPEP UPEP with immunofixation serum free light chains
bull Additional labs neg Renal ultrasound shows that both kidneys are slightly reduced in size and are mildly echogenic with no mass or hydronephrosis
bull What is your diagnosis
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileMain_complications_of_persistent_high_blood_pressurepngCreative Commons License associated httpcreativecommonsorglicensesby-sa30
bull 3 months Howevermdashwe have evidence of structural abnormalities Could potentially stage at G3b A3 (red on the heat map)
bull Goal blood pressure
bull JNC 8 14090 NKF 13080
bull Additional lab needed for progression monitoring
bull Cbc renal panel phos Vit D iPTH uric acid urine micro (we already have the renal sono and urine proteincr ratio and lipid)
Selective renal angiography (left lower renal artery) after successful percutaneous balloon dilatation of the stenotic lesionFibromuscular dysplasia in an accessory renal artery causing renovascular hypertension
Secondary Hypertension
Images retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileRenal_FMD2jpg and httpcommonswikimediaorgwikiFileRenal_FMDjpgCreative Commons License associated httpcreativecommonsorglicensesby20deeden (both images)
CASE 2bull OS is a 64year old Hispanic female in for DM check She has had DM for 15+ years and is currently
taking metformin 1000mg bid Lisinopril 10mg a day atorvastatin 40mg a day Labs today showed the following
bull Hgba1c 86 cmp eGFR 50 lipid WNL proteincr ratio 650mg These results are similar to her last visit
bull Upon further hx-you find that she had a recent eye exam and has mild nonproliferaive retinopathy She does not have neuropathy or other ss
bull What further workup do you need
bull Renal sonogram urine micro iPTH vit D (25 OH) phos uric acid
bull Dx stage
bull G3a A3
bull What further treatment do you need
bull Improve glycemic control Increase Lisinopril to 20mg with a goal of 40mg Avoid NSAIDs or other nephrotoxic agents make sure meds are renally dosed monitor 3xyear nephro referral
MANAGEMENT OF CKD IN DIABETESeGFR Recommended
All patients
Yearly measurement of creatinine urinary albumin excretion potassium
45-60 Referral to a nephrologist if possibility for nondiabetickidney disease existsConsider dose adjustment of medicationsMonitor eGFR every 6 monthsMonitor electrolytes bicarbonate hemoglobin calcium phosphorus parathyroid hormone at least yearly
Assure vitamin D sufficiencyConsider bone density testingReferral for dietary counselling
American Diabetes Association Standards of Medical Care in Diabetes Microvascular complications and foot care Diabetes Care 2017 40 (Suppl 1) S88-S98
CASE 3
bull 19 year old African American woman presents to your clinic with complaints of fatigue joint pains a new rash on her face oral ulcer
bull On exam BP 15080 P 88 Afebrile 96 O2 sats on RAbull GEN No respiratory distress at restbull HEENT painless oral ulcer flat rash over malar eminences sparing the nasolabial fold pallor +bull Lungs CTAbull CVS S1S2 regularbull Abdomen soft NTbull Ext left elbow joint and bilateral wrist joints are swollen and tender
bull What would you orderbull CBC CMP ua urine microscopy (microalbumin or urine proteincr ratio) ANA esr RF anti-ccp uric acid TSH
CASE 3
bull Working dx fatigue oral ulcer joint pain
bull Basic Labs Na 135 K 55 Bicarb 18 BUN 50 Cr 35 eGFR 22 Ca 90 ANA + titer 1640
bull UA 3+ blood 3+ protein RBC casts +
bull Given these results what is the most likely diagnosis
bull What would you do
SYSTEMIC LUPUS ERYTHEMATOSUS (SLE)
bull SLE multisystemic disease Etiology unknown
bull Production of autoantibodies and immune complexes formation
bull There is renal involvement in the great majority of patients with SLE at some time of the evolution 66-90
SLE ndash LUPUS NEPHRITIS
bull Race SLE is more commonsevere in African americans than Caucasiansbull
bull Gender female-to-male ratio of 91
bull Age Most patients develop lupus nephritis early in their disease course SLE is more common among women in the third decade of life and lupus nephritis occurs in patients aged 20-40 years
bull Kidney Biopsy For staging lupus nephritis (Class 1-5)
CASE 5bull A 80 year old man who has not seen a PCP in many years
presents to your clinic for weakness for the past few months On further questioning he tells you that his bones also have been hurting lately and he has developed leg swelling in the past month or so
bull On exam bull BP 16090 P 88 Afebrilebull GEN Thin built manbull HEENT pallor presentbull Lungs clearbull CVS S1S2 regular no rub or gallopbull Abdomen soft NTbull Ext 2 + edema
CASE 5
bull Differentials
bull CHF MI Cancer arthritis
bull Labs
bull CBC CMP urine microscopy urine proteincr ratio ESR TSH EKG BNP pa and lat CXR
bull LABS Urine dipstick negative for protein or blood
bull Basic chem bull Na 136 (135-145) K 51 (35-55) Chloride 108 (96-106) Bicarb 25
Given this presentation and the labs (low anion gap and elevated calcium anemia kidney failure) what will you think of What will you order next
Serum and urine protein electrophoresis
Intratubular refractile casts with surrounding syncytial giant cell reaction with chronic tubulointerstitial nephritis and fibrosis characteristic of myeloma cast nephropathy
Kidney Biopsy
CASE STUDYbull A 35 year old African American woman was seen in the clinic for
chronic cough and dyspnea on exertion She gave history of vague symptoms of fatigue and weight loss of 20 Ibs over the last six months
bull List some differentialsbull TB sarcoid lupus thyroid problems PEbull What would you orderbull PPD cbc cmp UA TSH ANA pa and lat cxr
bull Her labs were significant for mildly elevated calcium level and a creatinine of 20 mgdL eGFR 37
bull She had 750 mg of proteinuriaday
bull PPD neg ANA neg TSH and other labs WNL
bull Assuming this is present more than 3 monthshelliphellipwhat is her ckd stage
bull G3b A3
bull What do we still need
CT scan of chest
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileAnterior_mediastinal_mass_thymomajpgCreative Commons License associated httpcreativecommonsorglicensesby20deeden
CXR ndash HILAR LYMPHADENOPATHY
WHATS NEEDED NEXT
bull Biopsy of hilar lymphadenopathy or renal biopsy
bull DX sarcoidosis
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileSarcoidosis_signs_and_symptomsjpgThis work is in the public domain in the United States because it is a work of the United States Federal Government under the terms of Title 17 Chapter 1 Section 105 of the US Code
NEWLY DX CKD
bull 1) urinalysis microscopy ultrasound proteincr ratio
bull If obstruction-treat
bull No obstruction
bull Hx critical (consider myeloma if high risk)
bull glomerular bleeding or albumin in urine
bull Yes workup for glomerular causes (ANArf hep B C upep spep ANCA complement C3 C4)
bull No sterile pyruria-consider interstitial nephritis
bull High risk renovascular disease Evaluate renovascular disease
Additional Online Resources for CKD LearningbullNational Kidney Foundation wwwkidneyorgbullUnited States Renal Data Service wwwusrdsorgbullCDCrsquos CKD Surveillance Project
httpnccdcdcgovckdbullNational Kidney Disease Education Program
(NKDEP) httpnkdepnihgov
BIBLIOGRAPHY
bull Afzali B amp Goldsmith D J (2016 June 29) Statins and chronic kidney disease (G C Curhan amp A M Sheridan Eds) Retrieved 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsstatins-and-chronic-kidney-disease
bull American Diabetes Association Standards of Medical Care in Diabetes (2017) Microvascular complications and foot care Diabetes Care 2017 (40) S88-S98
bull American Diabetes Association Standards of Medical Care in Diabetes (2017) Microvascular complications and foot care Diabetes Care 40 (suppl 1) S88-S98
bull Berns J S (2017 Mar 22) Treatment of anemia in nondialysis chronic kidney disease (T A Golper amp A M Sheridan Eds) Retrieved from UpToDate httpswww-uptodate-comproxywichitaeducontentstreatment-of-anemia-in-nondialysis-chronic-kidney-disease
bull Chan M Dall A T Fletcher K E Lu N amp Trivedi H (2007) Outcomes in patients with chronic kidney disease referred late to nephrologists a meta-analysis American Journal of Medicine 120(12) 1063-1070
bull Coresh J Selvin E amp Stevens L A (2007) Prevalence of chronic kidny disease in the United States JAMA 298(17) doi101001jama298172038
bull de Brito-Ashurst I Varagunam M Raftery M amp Yagoob M (2009) Bicarbonate supplementation slows progression of CKD and improves nutritional status Journal of American Society of Nephrology (20) 2075-2084
BIBLIOGRAPHY
bull Duncan L Heathcoat J Djurdjev O amp Levin A (2001) Screening for renal disease using serum creatinine who are we missing Nephrology Dialysis and Transplant 16(5) 1042-1046
bull Dunkler D Gao P Lee S F Heinz G Clase C M Tobe S Oberbauer R (2015 August 7) Risk prediction for early CKD in type 2 diabetes Retrieved from Clinical Journal of the American Society of Nephrology httpcjasnasnjournalsorgcontent1081371fullsid=61422554-a5f1-41ac-b696-dcd3b12bd268
bull Fatehi P amp Chi-yuan H (September 15 2016) Diagnostic approach to the patient with newly identified chronic kidney disease (G C Curhan amp A M Sheridan Eds) Retrieved May 7 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsdiagnostic-approach-to-the-patient-with-newly-identified-chronic-kidney-disease
bull Fink J e (2009) Chronic Kidney Disease as an Under-Recognized Threat to Patient Safety American journal of kidney diseases the official journal of the National Kidney Foundation 53(4) 681-688
bull Gaffo A L amp Saag K G (2008 Nov) Management of hyperuricemia and gout in CKD doihttpdxdoiorg101053jajkd200807035
bull Hebert L A amp Parikh S V (2014 June 18) Differential diagnosis and evaluation of glomerular disease (R J Glassock amp A Q Lam Eds) Retrieved May 7 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsdifferential-diagnosis-and-evaluation-of-glomerular-disease
bull Inker L Perrone R D Sterns R H amp Forman J P (2017 March 7) Assessment of kidney function Retrieved from UpToDate httpswww-uptodate-comproxywichitaeducontentsassessment-of-kidney-functionsource=search_resultampsearch=creatinineampselectedTitle=1~150
BIBLIOGRAPHY
bull James P A Ortiz E amp Et Al (2014) Evidence based guideline for the management of high blood pressure in adults (JNC) JAMA 311(5) 507-520
bull Kidney Disease Improving Global Outcomes (KDIGO) CKD Work Group (2013 January) KDIGO 2012 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease Retrieved from Kidney International Supplement httpwwwkidney-internationalorg
bull Kunz R Friedrich C Wolbers M amp Mann J F (2008) Meta-analysis effect of monotherapy and combination therapy with inhibitors of the renin angiotensin system on proteinuria in renal disease Annals of Internal Medicine 148(1) 30-48
bull Levey A Stevens L A Schmid C H Castro A F Feldman H I Kusek J W Coresh J (2009) A new equation to estimate glomerular filtration rate Annals of Internal Medicine 150(9) 604-612
bull Levin A Bakris G L Molitch M Smulders M M Williams L A amp Andress D L (2007 Jan) Prevalence of abnormal serum vitamin D PTH calcium and phosphorus in patients with chronic kidney disease results of the study to evaluate early kidney disease Kidney International 71(1) 31-38 Retrieved from PubMED
bull Mahajan A Simoni J Sheather S Broglio K Rajab M amp Wesson D (2010) Daily oral sodium bicarbonate preserves glomerular filtration rate by slowing its decline in early hypertensive nephropathy Kidney International (78_ 303-309
bull Mann J Schmieder R E amp McQueen M (2008) Renal outcomes with telmisartan ramipril or both in people at high vascular risk (the ONTARGET study) a multicentre randomised doubleblind ocntrolled trial Lancet 372(9638) 547-533
BIBLIOGRAPHY
bull Matovinović M S (2009) Pathophysiology and classification of kidney disease Retrieved from The Journal of the International Federation of Clinical Chemistry and Laboratory Medicine httpwwwifccorgifccfilesdocs20010902pdf
bull Moe S Drueke T Lameire N amp Eknoyan G (2007 Jan) Chronic kidney disease-mineral-bone disorder a new paradigmdoi101053jackd200610005
bull Murtagh F E Marsh J E Donohoe P Ekbal N J Sheerin N S amp Harris F E (2007 July) Dialysis or not A comparative survival study of patients over 75 years with chronic kidney disease stage 5 Retrieved from Nephrology Dialysis and Transplant 22(7) httpswwwncbinlmnihgovpubmed17412702
bull National Kidney Foundation (2002) KDOQI clinical practice guidelines for chronic kidney disease evaluation classification andstratification American Journal of Kidney Disease S1-S266
bull National Kidney Foundation (2014 November 5) Fact Sheets Retrieved from httpwwwkidneyorgnewsnewsroomfactsheetsFastFacts
bull Pal S (2012 June 2) Trends in chronic kidney disease Retrieved from US Pharmacist (37)6 httpswwwuspharmacistcomarticletrends-in-chronic-kidney-disease
bull Qunibi W amp Henrich W L (2017 Jan 19) Overview of chronic kidney disease-mineral and bone disorder (J Berns amp A M Sheridan Eds) Retrieved from UpToDate httpswww-uptodate-comoverview-of-chronic-kidney-disease-mineral-and-bone-disorder-ckd-mbd
bull Rosenberg M (2016 Feb 24) Overview of the management of chronic kidney disease in adults (G C Curhan amp A M Sheridan Eds) Retrieved from UpToDate UpToDate httpswww-uptodate-comproxywichitaeducontentsoverview-of-the-management-of-chronic-kidney-disease-in-adults
BIBLIOGRAPHY
bull Szczech L Stewart R C Hsu-Lin S DeLosky R J Astor B C Fox C H Vassalotti J A (2014) Primary care detection of chronic kidney disease in adults with type 2 diabetes The ADD-CKD Study (Awareness Detection and Drug Therapy in type 2 diabetes and chronic kidney disease PLOS doihttpsdoiorg101371journalpone0110535
bull USRDS (2016) Annual data report 2016 Epidemiology of kidney disease in the United States Retrieved from United States Renal Data System httpswwwusrdsorgadraspx
bull Vasudev B amp Vasudev M (2012) A model curriculum for residents rotating in nephrology MedEDPORTAL doihttpdoiorg1015766mep_2374-82658288
bull Wei L MacDonald T M Jennings C Sheng X amp Flynn R W (2013) Estimated GFR reporting is associated with decreased nonsteroidal anti-inflammatory drug prescribing and increased renal function Kidney International (84)1 174-178
chronic kidney disease in primary care
CKD as a Public Health Issue
Slide Number 3
Costs of CKD in 2013 dollarsUSRDS report
Steps to CKD Patient Care
Renal anatomy and physiology
Definition of Chronic Kidney Disease
CKD Risk Factors
Gaps in CKD Diagnosis
Slide Number 10
Steps to CKD Patient Care
creatinine
Glomerular filtration rate
Slide Number 14
Slide Number 15
Use These Equations Cautiously if at all in hellip
lab albumin creatinine ratio
The New CKD Categories
Steps to CKD Patient Care
Slide Number 20
Kidney Involvement in Systemic Diseases
Slide Number 22
Slide Number 23
DysmorphicRenal Hematuria
Slide Number 25
If you have albuminuria or hematuria-order the following labs
bull Progression of disease ndash declining eGFR increasing proteinuria
bull Degree of proteinuria nephrotic syndrome gt 05-10 gd on ACEi or ARB therapy
bull Etiology of CKD not certain
bull Need help with disease management
bull Indications for kidney biopsy
Rosenberg 2016
WHEN TO REFER
STEPS TO CKD PATIENT CARE
1 CKD definition and risks2 Assess GFR albuminuria3 Determine etiology4 Assess for evidence of progression5 Assess for associated complications6 Discuss dialysistransplantation
KIDNEY TRANSPLANTATION
bull Treatment of choice for ESRDbull Improves quality of lifebull Waiting list time varies-3-5 yearsbull 3 year survival rate after transplantation is 83-94bull Increased risk of cancer
STARTING DIALYSIS IN THE ELDERLYhellipOR NOT
bull Among patients gt 75 yrs with stage 5 CKD who chose to NOT start dialysisbull Overall more likely to die over next 1-2 years bull But if they had ischemic heart disease or other significant comorbidity NO
DIFFERENCE in survival
bull Active disease management and supportive care may be appropriate without starting dialysis in the ill elderly
bull Palliative care does not mean ldquono carerdquo
bull Must have end-of-life discussions
(Murtagh et al 2007)
CKD MANAGEMENTbull Diagnose cause and treat underlying conditionbull Stage per guidelinesbull Slow progression of kidney disease (ACE inhibitors)bull Monitor for complicationsmdashvolume overload hyperkalemia metabolic acidosis
hyperphosphatemia anorexia fatigue htn bone diseasebull Labs cmp cbc phos Vit D 25OH iPTH urine microscopy uric acid urine
proteincr ratio-frequency based off heat map Get sono at least oncebull Vaccinate influenza hep B pneumococcalbull Eval ASCVD risk-likely needs statinbull Possible dexa (donrsquot give bisphosphonates if GFRlt35 let specialist manage)bull Refer to nephrology when eGFR is lt30 (sometimes if higher risk-refer earlier)
CASE 1
bull 55 year old man with past medical history of headaches presents to your office for his first time visit to a PCP in over 30 years
bull He has no past history of being admitted to the hospital and he does not take any OTC medsNSAIDsherbal meds He has no history of ETOH abuse smoking or drug use
bull Vitals BP 180100 mmHg pulse 80 R 18
bull Exam No JVD S1S2 regular PMI shifted to the left no gallop no abdominal bruit pulses bilaterally equal and regular no leg edema
bull What would you order
bull EKG cbc cmp ua urine proteincr ratio lipid
LAB RESULTS
bull Labs reveal a creatinine of 22 mgdL eGFR 33 Urine shows no blood or casts Urineprotein ratio shows 1 gm protein24 hrs EKG shows LVH
bull Next step in workupbull Renal ultrasound 1st then SPEP UPEP with immunofixation serum free light chains
bull Additional labs neg Renal ultrasound shows that both kidneys are slightly reduced in size and are mildly echogenic with no mass or hydronephrosis
bull What is your diagnosis
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileMain_complications_of_persistent_high_blood_pressurepngCreative Commons License associated httpcreativecommonsorglicensesby-sa30
bull 3 months Howevermdashwe have evidence of structural abnormalities Could potentially stage at G3b A3 (red on the heat map)
bull Goal blood pressure
bull JNC 8 14090 NKF 13080
bull Additional lab needed for progression monitoring
bull Cbc renal panel phos Vit D iPTH uric acid urine micro (we already have the renal sono and urine proteincr ratio and lipid)
Selective renal angiography (left lower renal artery) after successful percutaneous balloon dilatation of the stenotic lesionFibromuscular dysplasia in an accessory renal artery causing renovascular hypertension
Secondary Hypertension
Images retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileRenal_FMD2jpg and httpcommonswikimediaorgwikiFileRenal_FMDjpgCreative Commons License associated httpcreativecommonsorglicensesby20deeden (both images)
CASE 2bull OS is a 64year old Hispanic female in for DM check She has had DM for 15+ years and is currently
taking metformin 1000mg bid Lisinopril 10mg a day atorvastatin 40mg a day Labs today showed the following
bull Hgba1c 86 cmp eGFR 50 lipid WNL proteincr ratio 650mg These results are similar to her last visit
bull Upon further hx-you find that she had a recent eye exam and has mild nonproliferaive retinopathy She does not have neuropathy or other ss
bull What further workup do you need
bull Renal sonogram urine micro iPTH vit D (25 OH) phos uric acid
bull Dx stage
bull G3a A3
bull What further treatment do you need
bull Improve glycemic control Increase Lisinopril to 20mg with a goal of 40mg Avoid NSAIDs or other nephrotoxic agents make sure meds are renally dosed monitor 3xyear nephro referral
MANAGEMENT OF CKD IN DIABETESeGFR Recommended
All patients
Yearly measurement of creatinine urinary albumin excretion potassium
45-60 Referral to a nephrologist if possibility for nondiabetickidney disease existsConsider dose adjustment of medicationsMonitor eGFR every 6 monthsMonitor electrolytes bicarbonate hemoglobin calcium phosphorus parathyroid hormone at least yearly
Assure vitamin D sufficiencyConsider bone density testingReferral for dietary counselling
American Diabetes Association Standards of Medical Care in Diabetes Microvascular complications and foot care Diabetes Care 2017 40 (Suppl 1) S88-S98
CASE 3
bull 19 year old African American woman presents to your clinic with complaints of fatigue joint pains a new rash on her face oral ulcer
bull On exam BP 15080 P 88 Afebrile 96 O2 sats on RAbull GEN No respiratory distress at restbull HEENT painless oral ulcer flat rash over malar eminences sparing the nasolabial fold pallor +bull Lungs CTAbull CVS S1S2 regularbull Abdomen soft NTbull Ext left elbow joint and bilateral wrist joints are swollen and tender
bull What would you orderbull CBC CMP ua urine microscopy (microalbumin or urine proteincr ratio) ANA esr RF anti-ccp uric acid TSH
CASE 3
bull Working dx fatigue oral ulcer joint pain
bull Basic Labs Na 135 K 55 Bicarb 18 BUN 50 Cr 35 eGFR 22 Ca 90 ANA + titer 1640
bull UA 3+ blood 3+ protein RBC casts +
bull Given these results what is the most likely diagnosis
bull What would you do
SYSTEMIC LUPUS ERYTHEMATOSUS (SLE)
bull SLE multisystemic disease Etiology unknown
bull Production of autoantibodies and immune complexes formation
bull There is renal involvement in the great majority of patients with SLE at some time of the evolution 66-90
SLE ndash LUPUS NEPHRITIS
bull Race SLE is more commonsevere in African americans than Caucasiansbull
bull Gender female-to-male ratio of 91
bull Age Most patients develop lupus nephritis early in their disease course SLE is more common among women in the third decade of life and lupus nephritis occurs in patients aged 20-40 years
bull Kidney Biopsy For staging lupus nephritis (Class 1-5)
CASE 5bull A 80 year old man who has not seen a PCP in many years
presents to your clinic for weakness for the past few months On further questioning he tells you that his bones also have been hurting lately and he has developed leg swelling in the past month or so
bull On exam bull BP 16090 P 88 Afebrilebull GEN Thin built manbull HEENT pallor presentbull Lungs clearbull CVS S1S2 regular no rub or gallopbull Abdomen soft NTbull Ext 2 + edema
CASE 5
bull Differentials
bull CHF MI Cancer arthritis
bull Labs
bull CBC CMP urine microscopy urine proteincr ratio ESR TSH EKG BNP pa and lat CXR
bull LABS Urine dipstick negative for protein or blood
bull Basic chem bull Na 136 (135-145) K 51 (35-55) Chloride 108 (96-106) Bicarb 25
Given this presentation and the labs (low anion gap and elevated calcium anemia kidney failure) what will you think of What will you order next
Serum and urine protein electrophoresis
Intratubular refractile casts with surrounding syncytial giant cell reaction with chronic tubulointerstitial nephritis and fibrosis characteristic of myeloma cast nephropathy
Kidney Biopsy
CASE STUDYbull A 35 year old African American woman was seen in the clinic for
chronic cough and dyspnea on exertion She gave history of vague symptoms of fatigue and weight loss of 20 Ibs over the last six months
bull List some differentialsbull TB sarcoid lupus thyroid problems PEbull What would you orderbull PPD cbc cmp UA TSH ANA pa and lat cxr
bull Her labs were significant for mildly elevated calcium level and a creatinine of 20 mgdL eGFR 37
bull She had 750 mg of proteinuriaday
bull PPD neg ANA neg TSH and other labs WNL
bull Assuming this is present more than 3 monthshelliphellipwhat is her ckd stage
bull G3b A3
bull What do we still need
CT scan of chest
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileAnterior_mediastinal_mass_thymomajpgCreative Commons License associated httpcreativecommonsorglicensesby20deeden
CXR ndash HILAR LYMPHADENOPATHY
WHATS NEEDED NEXT
bull Biopsy of hilar lymphadenopathy or renal biopsy
bull DX sarcoidosis
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileSarcoidosis_signs_and_symptomsjpgThis work is in the public domain in the United States because it is a work of the United States Federal Government under the terms of Title 17 Chapter 1 Section 105 of the US Code
NEWLY DX CKD
bull 1) urinalysis microscopy ultrasound proteincr ratio
bull If obstruction-treat
bull No obstruction
bull Hx critical (consider myeloma if high risk)
bull glomerular bleeding or albumin in urine
bull Yes workup for glomerular causes (ANArf hep B C upep spep ANCA complement C3 C4)
bull No sterile pyruria-consider interstitial nephritis
bull High risk renovascular disease Evaluate renovascular disease
Additional Online Resources for CKD LearningbullNational Kidney Foundation wwwkidneyorgbullUnited States Renal Data Service wwwusrdsorgbullCDCrsquos CKD Surveillance Project
httpnccdcdcgovckdbullNational Kidney Disease Education Program
(NKDEP) httpnkdepnihgov
BIBLIOGRAPHY
bull Afzali B amp Goldsmith D J (2016 June 29) Statins and chronic kidney disease (G C Curhan amp A M Sheridan Eds) Retrieved 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsstatins-and-chronic-kidney-disease
bull American Diabetes Association Standards of Medical Care in Diabetes (2017) Microvascular complications and foot care Diabetes Care 2017 (40) S88-S98
bull American Diabetes Association Standards of Medical Care in Diabetes (2017) Microvascular complications and foot care Diabetes Care 40 (suppl 1) S88-S98
bull Berns J S (2017 Mar 22) Treatment of anemia in nondialysis chronic kidney disease (T A Golper amp A M Sheridan Eds) Retrieved from UpToDate httpswww-uptodate-comproxywichitaeducontentstreatment-of-anemia-in-nondialysis-chronic-kidney-disease
bull Chan M Dall A T Fletcher K E Lu N amp Trivedi H (2007) Outcomes in patients with chronic kidney disease referred late to nephrologists a meta-analysis American Journal of Medicine 120(12) 1063-1070
bull Coresh J Selvin E amp Stevens L A (2007) Prevalence of chronic kidny disease in the United States JAMA 298(17) doi101001jama298172038
bull de Brito-Ashurst I Varagunam M Raftery M amp Yagoob M (2009) Bicarbonate supplementation slows progression of CKD and improves nutritional status Journal of American Society of Nephrology (20) 2075-2084
BIBLIOGRAPHY
bull Duncan L Heathcoat J Djurdjev O amp Levin A (2001) Screening for renal disease using serum creatinine who are we missing Nephrology Dialysis and Transplant 16(5) 1042-1046
bull Dunkler D Gao P Lee S F Heinz G Clase C M Tobe S Oberbauer R (2015 August 7) Risk prediction for early CKD in type 2 diabetes Retrieved from Clinical Journal of the American Society of Nephrology httpcjasnasnjournalsorgcontent1081371fullsid=61422554-a5f1-41ac-b696-dcd3b12bd268
bull Fatehi P amp Chi-yuan H (September 15 2016) Diagnostic approach to the patient with newly identified chronic kidney disease (G C Curhan amp A M Sheridan Eds) Retrieved May 7 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsdiagnostic-approach-to-the-patient-with-newly-identified-chronic-kidney-disease
bull Fink J e (2009) Chronic Kidney Disease as an Under-Recognized Threat to Patient Safety American journal of kidney diseases the official journal of the National Kidney Foundation 53(4) 681-688
bull Gaffo A L amp Saag K G (2008 Nov) Management of hyperuricemia and gout in CKD doihttpdxdoiorg101053jajkd200807035
bull Hebert L A amp Parikh S V (2014 June 18) Differential diagnosis and evaluation of glomerular disease (R J Glassock amp A Q Lam Eds) Retrieved May 7 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsdifferential-diagnosis-and-evaluation-of-glomerular-disease
bull Inker L Perrone R D Sterns R H amp Forman J P (2017 March 7) Assessment of kidney function Retrieved from UpToDate httpswww-uptodate-comproxywichitaeducontentsassessment-of-kidney-functionsource=search_resultampsearch=creatinineampselectedTitle=1~150
BIBLIOGRAPHY
bull James P A Ortiz E amp Et Al (2014) Evidence based guideline for the management of high blood pressure in adults (JNC) JAMA 311(5) 507-520
bull Kidney Disease Improving Global Outcomes (KDIGO) CKD Work Group (2013 January) KDIGO 2012 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease Retrieved from Kidney International Supplement httpwwwkidney-internationalorg
bull Kunz R Friedrich C Wolbers M amp Mann J F (2008) Meta-analysis effect of monotherapy and combination therapy with inhibitors of the renin angiotensin system on proteinuria in renal disease Annals of Internal Medicine 148(1) 30-48
bull Levey A Stevens L A Schmid C H Castro A F Feldman H I Kusek J W Coresh J (2009) A new equation to estimate glomerular filtration rate Annals of Internal Medicine 150(9) 604-612
bull Levin A Bakris G L Molitch M Smulders M M Williams L A amp Andress D L (2007 Jan) Prevalence of abnormal serum vitamin D PTH calcium and phosphorus in patients with chronic kidney disease results of the study to evaluate early kidney disease Kidney International 71(1) 31-38 Retrieved from PubMED
bull Mahajan A Simoni J Sheather S Broglio K Rajab M amp Wesson D (2010) Daily oral sodium bicarbonate preserves glomerular filtration rate by slowing its decline in early hypertensive nephropathy Kidney International (78_ 303-309
bull Mann J Schmieder R E amp McQueen M (2008) Renal outcomes with telmisartan ramipril or both in people at high vascular risk (the ONTARGET study) a multicentre randomised doubleblind ocntrolled trial Lancet 372(9638) 547-533
BIBLIOGRAPHY
bull Matovinović M S (2009) Pathophysiology and classification of kidney disease Retrieved from The Journal of the International Federation of Clinical Chemistry and Laboratory Medicine httpwwwifccorgifccfilesdocs20010902pdf
bull Moe S Drueke T Lameire N amp Eknoyan G (2007 Jan) Chronic kidney disease-mineral-bone disorder a new paradigmdoi101053jackd200610005
bull Murtagh F E Marsh J E Donohoe P Ekbal N J Sheerin N S amp Harris F E (2007 July) Dialysis or not A comparative survival study of patients over 75 years with chronic kidney disease stage 5 Retrieved from Nephrology Dialysis and Transplant 22(7) httpswwwncbinlmnihgovpubmed17412702
bull National Kidney Foundation (2002) KDOQI clinical practice guidelines for chronic kidney disease evaluation classification andstratification American Journal of Kidney Disease S1-S266
bull National Kidney Foundation (2014 November 5) Fact Sheets Retrieved from httpwwwkidneyorgnewsnewsroomfactsheetsFastFacts
bull Pal S (2012 June 2) Trends in chronic kidney disease Retrieved from US Pharmacist (37)6 httpswwwuspharmacistcomarticletrends-in-chronic-kidney-disease
bull Qunibi W amp Henrich W L (2017 Jan 19) Overview of chronic kidney disease-mineral and bone disorder (J Berns amp A M Sheridan Eds) Retrieved from UpToDate httpswww-uptodate-comoverview-of-chronic-kidney-disease-mineral-and-bone-disorder-ckd-mbd
bull Rosenberg M (2016 Feb 24) Overview of the management of chronic kidney disease in adults (G C Curhan amp A M Sheridan Eds) Retrieved from UpToDate UpToDate httpswww-uptodate-comproxywichitaeducontentsoverview-of-the-management-of-chronic-kidney-disease-in-adults
BIBLIOGRAPHY
bull Szczech L Stewart R C Hsu-Lin S DeLosky R J Astor B C Fox C H Vassalotti J A (2014) Primary care detection of chronic kidney disease in adults with type 2 diabetes The ADD-CKD Study (Awareness Detection and Drug Therapy in type 2 diabetes and chronic kidney disease PLOS doihttpsdoiorg101371journalpone0110535
bull USRDS (2016) Annual data report 2016 Epidemiology of kidney disease in the United States Retrieved from United States Renal Data System httpswwwusrdsorgadraspx
bull Vasudev B amp Vasudev M (2012) A model curriculum for residents rotating in nephrology MedEDPORTAL doihttpdoiorg1015766mep_2374-82658288
bull Wei L MacDonald T M Jennings C Sheng X amp Flynn R W (2013) Estimated GFR reporting is associated with decreased nonsteroidal anti-inflammatory drug prescribing and increased renal function Kidney International (84)1 174-178
chronic kidney disease in primary care
CKD as a Public Health Issue
Slide Number 3
Costs of CKD in 2013 dollarsUSRDS report
Steps to CKD Patient Care
Renal anatomy and physiology
Definition of Chronic Kidney Disease
CKD Risk Factors
Gaps in CKD Diagnosis
Slide Number 10
Steps to CKD Patient Care
creatinine
Glomerular filtration rate
Slide Number 14
Slide Number 15
Use These Equations Cautiously if at all in hellip
lab albumin creatinine ratio
The New CKD Categories
Steps to CKD Patient Care
Slide Number 20
Kidney Involvement in Systemic Diseases
Slide Number 22
Slide Number 23
DysmorphicRenal Hematuria
Slide Number 25
If you have albuminuria or hematuria-order the following labs
bull Progression of disease ndash declining eGFR increasing proteinuria
bull Degree of proteinuria nephrotic syndrome gt 05-10 gd on ACEi or ARB therapy
bull Etiology of CKD not certain
bull Need help with disease management
bull Indications for kidney biopsy
Rosenberg 2016
WHEN TO REFER
STEPS TO CKD PATIENT CARE
1 CKD definition and risks2 Assess GFR albuminuria3 Determine etiology4 Assess for evidence of progression5 Assess for associated complications6 Discuss dialysistransplantation
KIDNEY TRANSPLANTATION
bull Treatment of choice for ESRDbull Improves quality of lifebull Waiting list time varies-3-5 yearsbull 3 year survival rate after transplantation is 83-94bull Increased risk of cancer
STARTING DIALYSIS IN THE ELDERLYhellipOR NOT
bull Among patients gt 75 yrs with stage 5 CKD who chose to NOT start dialysisbull Overall more likely to die over next 1-2 years bull But if they had ischemic heart disease or other significant comorbidity NO
DIFFERENCE in survival
bull Active disease management and supportive care may be appropriate without starting dialysis in the ill elderly
bull Palliative care does not mean ldquono carerdquo
bull Must have end-of-life discussions
(Murtagh et al 2007)
CKD MANAGEMENTbull Diagnose cause and treat underlying conditionbull Stage per guidelinesbull Slow progression of kidney disease (ACE inhibitors)bull Monitor for complicationsmdashvolume overload hyperkalemia metabolic acidosis
hyperphosphatemia anorexia fatigue htn bone diseasebull Labs cmp cbc phos Vit D 25OH iPTH urine microscopy uric acid urine
proteincr ratio-frequency based off heat map Get sono at least oncebull Vaccinate influenza hep B pneumococcalbull Eval ASCVD risk-likely needs statinbull Possible dexa (donrsquot give bisphosphonates if GFRlt35 let specialist manage)bull Refer to nephrology when eGFR is lt30 (sometimes if higher risk-refer earlier)
CASE 1
bull 55 year old man with past medical history of headaches presents to your office for his first time visit to a PCP in over 30 years
bull He has no past history of being admitted to the hospital and he does not take any OTC medsNSAIDsherbal meds He has no history of ETOH abuse smoking or drug use
bull Vitals BP 180100 mmHg pulse 80 R 18
bull Exam No JVD S1S2 regular PMI shifted to the left no gallop no abdominal bruit pulses bilaterally equal and regular no leg edema
bull What would you order
bull EKG cbc cmp ua urine proteincr ratio lipid
LAB RESULTS
bull Labs reveal a creatinine of 22 mgdL eGFR 33 Urine shows no blood or casts Urineprotein ratio shows 1 gm protein24 hrs EKG shows LVH
bull Next step in workupbull Renal ultrasound 1st then SPEP UPEP with immunofixation serum free light chains
bull Additional labs neg Renal ultrasound shows that both kidneys are slightly reduced in size and are mildly echogenic with no mass or hydronephrosis
bull What is your diagnosis
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileMain_complications_of_persistent_high_blood_pressurepngCreative Commons License associated httpcreativecommonsorglicensesby-sa30
bull 3 months Howevermdashwe have evidence of structural abnormalities Could potentially stage at G3b A3 (red on the heat map)
bull Goal blood pressure
bull JNC 8 14090 NKF 13080
bull Additional lab needed for progression monitoring
bull Cbc renal panel phos Vit D iPTH uric acid urine micro (we already have the renal sono and urine proteincr ratio and lipid)
Selective renal angiography (left lower renal artery) after successful percutaneous balloon dilatation of the stenotic lesionFibromuscular dysplasia in an accessory renal artery causing renovascular hypertension
Secondary Hypertension
Images retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileRenal_FMD2jpg and httpcommonswikimediaorgwikiFileRenal_FMDjpgCreative Commons License associated httpcreativecommonsorglicensesby20deeden (both images)
CASE 2bull OS is a 64year old Hispanic female in for DM check She has had DM for 15+ years and is currently
taking metformin 1000mg bid Lisinopril 10mg a day atorvastatin 40mg a day Labs today showed the following
bull Hgba1c 86 cmp eGFR 50 lipid WNL proteincr ratio 650mg These results are similar to her last visit
bull Upon further hx-you find that she had a recent eye exam and has mild nonproliferaive retinopathy She does not have neuropathy or other ss
bull What further workup do you need
bull Renal sonogram urine micro iPTH vit D (25 OH) phos uric acid
bull Dx stage
bull G3a A3
bull What further treatment do you need
bull Improve glycemic control Increase Lisinopril to 20mg with a goal of 40mg Avoid NSAIDs or other nephrotoxic agents make sure meds are renally dosed monitor 3xyear nephro referral
MANAGEMENT OF CKD IN DIABETESeGFR Recommended
All patients
Yearly measurement of creatinine urinary albumin excretion potassium
45-60 Referral to a nephrologist if possibility for nondiabetickidney disease existsConsider dose adjustment of medicationsMonitor eGFR every 6 monthsMonitor electrolytes bicarbonate hemoglobin calcium phosphorus parathyroid hormone at least yearly
Assure vitamin D sufficiencyConsider bone density testingReferral for dietary counselling
American Diabetes Association Standards of Medical Care in Diabetes Microvascular complications and foot care Diabetes Care 2017 40 (Suppl 1) S88-S98
CASE 3
bull 19 year old African American woman presents to your clinic with complaints of fatigue joint pains a new rash on her face oral ulcer
bull On exam BP 15080 P 88 Afebrile 96 O2 sats on RAbull GEN No respiratory distress at restbull HEENT painless oral ulcer flat rash over malar eminences sparing the nasolabial fold pallor +bull Lungs CTAbull CVS S1S2 regularbull Abdomen soft NTbull Ext left elbow joint and bilateral wrist joints are swollen and tender
bull What would you orderbull CBC CMP ua urine microscopy (microalbumin or urine proteincr ratio) ANA esr RF anti-ccp uric acid TSH
CASE 3
bull Working dx fatigue oral ulcer joint pain
bull Basic Labs Na 135 K 55 Bicarb 18 BUN 50 Cr 35 eGFR 22 Ca 90 ANA + titer 1640
bull UA 3+ blood 3+ protein RBC casts +
bull Given these results what is the most likely diagnosis
bull What would you do
SYSTEMIC LUPUS ERYTHEMATOSUS (SLE)
bull SLE multisystemic disease Etiology unknown
bull Production of autoantibodies and immune complexes formation
bull There is renal involvement in the great majority of patients with SLE at some time of the evolution 66-90
SLE ndash LUPUS NEPHRITIS
bull Race SLE is more commonsevere in African americans than Caucasiansbull
bull Gender female-to-male ratio of 91
bull Age Most patients develop lupus nephritis early in their disease course SLE is more common among women in the third decade of life and lupus nephritis occurs in patients aged 20-40 years
bull Kidney Biopsy For staging lupus nephritis (Class 1-5)
CASE 5bull A 80 year old man who has not seen a PCP in many years
presents to your clinic for weakness for the past few months On further questioning he tells you that his bones also have been hurting lately and he has developed leg swelling in the past month or so
bull On exam bull BP 16090 P 88 Afebrilebull GEN Thin built manbull HEENT pallor presentbull Lungs clearbull CVS S1S2 regular no rub or gallopbull Abdomen soft NTbull Ext 2 + edema
CASE 5
bull Differentials
bull CHF MI Cancer arthritis
bull Labs
bull CBC CMP urine microscopy urine proteincr ratio ESR TSH EKG BNP pa and lat CXR
bull LABS Urine dipstick negative for protein or blood
bull Basic chem bull Na 136 (135-145) K 51 (35-55) Chloride 108 (96-106) Bicarb 25
Given this presentation and the labs (low anion gap and elevated calcium anemia kidney failure) what will you think of What will you order next
Serum and urine protein electrophoresis
Intratubular refractile casts with surrounding syncytial giant cell reaction with chronic tubulointerstitial nephritis and fibrosis characteristic of myeloma cast nephropathy
Kidney Biopsy
CASE STUDYbull A 35 year old African American woman was seen in the clinic for
chronic cough and dyspnea on exertion She gave history of vague symptoms of fatigue and weight loss of 20 Ibs over the last six months
bull List some differentialsbull TB sarcoid lupus thyroid problems PEbull What would you orderbull PPD cbc cmp UA TSH ANA pa and lat cxr
bull Her labs were significant for mildly elevated calcium level and a creatinine of 20 mgdL eGFR 37
bull She had 750 mg of proteinuriaday
bull PPD neg ANA neg TSH and other labs WNL
bull Assuming this is present more than 3 monthshelliphellipwhat is her ckd stage
bull G3b A3
bull What do we still need
CT scan of chest
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileAnterior_mediastinal_mass_thymomajpgCreative Commons License associated httpcreativecommonsorglicensesby20deeden
CXR ndash HILAR LYMPHADENOPATHY
WHATS NEEDED NEXT
bull Biopsy of hilar lymphadenopathy or renal biopsy
bull DX sarcoidosis
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileSarcoidosis_signs_and_symptomsjpgThis work is in the public domain in the United States because it is a work of the United States Federal Government under the terms of Title 17 Chapter 1 Section 105 of the US Code
NEWLY DX CKD
bull 1) urinalysis microscopy ultrasound proteincr ratio
bull If obstruction-treat
bull No obstruction
bull Hx critical (consider myeloma if high risk)
bull glomerular bleeding or albumin in urine
bull Yes workup for glomerular causes (ANArf hep B C upep spep ANCA complement C3 C4)
bull No sterile pyruria-consider interstitial nephritis
bull High risk renovascular disease Evaluate renovascular disease
Additional Online Resources for CKD LearningbullNational Kidney Foundation wwwkidneyorgbullUnited States Renal Data Service wwwusrdsorgbullCDCrsquos CKD Surveillance Project
httpnccdcdcgovckdbullNational Kidney Disease Education Program
(NKDEP) httpnkdepnihgov
BIBLIOGRAPHY
bull Afzali B amp Goldsmith D J (2016 June 29) Statins and chronic kidney disease (G C Curhan amp A M Sheridan Eds) Retrieved 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsstatins-and-chronic-kidney-disease
bull American Diabetes Association Standards of Medical Care in Diabetes (2017) Microvascular complications and foot care Diabetes Care 2017 (40) S88-S98
bull American Diabetes Association Standards of Medical Care in Diabetes (2017) Microvascular complications and foot care Diabetes Care 40 (suppl 1) S88-S98
bull Berns J S (2017 Mar 22) Treatment of anemia in nondialysis chronic kidney disease (T A Golper amp A M Sheridan Eds) Retrieved from UpToDate httpswww-uptodate-comproxywichitaeducontentstreatment-of-anemia-in-nondialysis-chronic-kidney-disease
bull Chan M Dall A T Fletcher K E Lu N amp Trivedi H (2007) Outcomes in patients with chronic kidney disease referred late to nephrologists a meta-analysis American Journal of Medicine 120(12) 1063-1070
bull Coresh J Selvin E amp Stevens L A (2007) Prevalence of chronic kidny disease in the United States JAMA 298(17) doi101001jama298172038
bull de Brito-Ashurst I Varagunam M Raftery M amp Yagoob M (2009) Bicarbonate supplementation slows progression of CKD and improves nutritional status Journal of American Society of Nephrology (20) 2075-2084
BIBLIOGRAPHY
bull Duncan L Heathcoat J Djurdjev O amp Levin A (2001) Screening for renal disease using serum creatinine who are we missing Nephrology Dialysis and Transplant 16(5) 1042-1046
bull Dunkler D Gao P Lee S F Heinz G Clase C M Tobe S Oberbauer R (2015 August 7) Risk prediction for early CKD in type 2 diabetes Retrieved from Clinical Journal of the American Society of Nephrology httpcjasnasnjournalsorgcontent1081371fullsid=61422554-a5f1-41ac-b696-dcd3b12bd268
bull Fatehi P amp Chi-yuan H (September 15 2016) Diagnostic approach to the patient with newly identified chronic kidney disease (G C Curhan amp A M Sheridan Eds) Retrieved May 7 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsdiagnostic-approach-to-the-patient-with-newly-identified-chronic-kidney-disease
bull Fink J e (2009) Chronic Kidney Disease as an Under-Recognized Threat to Patient Safety American journal of kidney diseases the official journal of the National Kidney Foundation 53(4) 681-688
bull Gaffo A L amp Saag K G (2008 Nov) Management of hyperuricemia and gout in CKD doihttpdxdoiorg101053jajkd200807035
bull Hebert L A amp Parikh S V (2014 June 18) Differential diagnosis and evaluation of glomerular disease (R J Glassock amp A Q Lam Eds) Retrieved May 7 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsdifferential-diagnosis-and-evaluation-of-glomerular-disease
bull Inker L Perrone R D Sterns R H amp Forman J P (2017 March 7) Assessment of kidney function Retrieved from UpToDate httpswww-uptodate-comproxywichitaeducontentsassessment-of-kidney-functionsource=search_resultampsearch=creatinineampselectedTitle=1~150
BIBLIOGRAPHY
bull James P A Ortiz E amp Et Al (2014) Evidence based guideline for the management of high blood pressure in adults (JNC) JAMA 311(5) 507-520
bull Kidney Disease Improving Global Outcomes (KDIGO) CKD Work Group (2013 January) KDIGO 2012 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease Retrieved from Kidney International Supplement httpwwwkidney-internationalorg
bull Kunz R Friedrich C Wolbers M amp Mann J F (2008) Meta-analysis effect of monotherapy and combination therapy with inhibitors of the renin angiotensin system on proteinuria in renal disease Annals of Internal Medicine 148(1) 30-48
bull Levey A Stevens L A Schmid C H Castro A F Feldman H I Kusek J W Coresh J (2009) A new equation to estimate glomerular filtration rate Annals of Internal Medicine 150(9) 604-612
bull Levin A Bakris G L Molitch M Smulders M M Williams L A amp Andress D L (2007 Jan) Prevalence of abnormal serum vitamin D PTH calcium and phosphorus in patients with chronic kidney disease results of the study to evaluate early kidney disease Kidney International 71(1) 31-38 Retrieved from PubMED
bull Mahajan A Simoni J Sheather S Broglio K Rajab M amp Wesson D (2010) Daily oral sodium bicarbonate preserves glomerular filtration rate by slowing its decline in early hypertensive nephropathy Kidney International (78_ 303-309
bull Mann J Schmieder R E amp McQueen M (2008) Renal outcomes with telmisartan ramipril or both in people at high vascular risk (the ONTARGET study) a multicentre randomised doubleblind ocntrolled trial Lancet 372(9638) 547-533
BIBLIOGRAPHY
bull Matovinović M S (2009) Pathophysiology and classification of kidney disease Retrieved from The Journal of the International Federation of Clinical Chemistry and Laboratory Medicine httpwwwifccorgifccfilesdocs20010902pdf
bull Moe S Drueke T Lameire N amp Eknoyan G (2007 Jan) Chronic kidney disease-mineral-bone disorder a new paradigmdoi101053jackd200610005
bull Murtagh F E Marsh J E Donohoe P Ekbal N J Sheerin N S amp Harris F E (2007 July) Dialysis or not A comparative survival study of patients over 75 years with chronic kidney disease stage 5 Retrieved from Nephrology Dialysis and Transplant 22(7) httpswwwncbinlmnihgovpubmed17412702
bull National Kidney Foundation (2002) KDOQI clinical practice guidelines for chronic kidney disease evaluation classification andstratification American Journal of Kidney Disease S1-S266
bull National Kidney Foundation (2014 November 5) Fact Sheets Retrieved from httpwwwkidneyorgnewsnewsroomfactsheetsFastFacts
bull Pal S (2012 June 2) Trends in chronic kidney disease Retrieved from US Pharmacist (37)6 httpswwwuspharmacistcomarticletrends-in-chronic-kidney-disease
bull Qunibi W amp Henrich W L (2017 Jan 19) Overview of chronic kidney disease-mineral and bone disorder (J Berns amp A M Sheridan Eds) Retrieved from UpToDate httpswww-uptodate-comoverview-of-chronic-kidney-disease-mineral-and-bone-disorder-ckd-mbd
bull Rosenberg M (2016 Feb 24) Overview of the management of chronic kidney disease in adults (G C Curhan amp A M Sheridan Eds) Retrieved from UpToDate UpToDate httpswww-uptodate-comproxywichitaeducontentsoverview-of-the-management-of-chronic-kidney-disease-in-adults
BIBLIOGRAPHY
bull Szczech L Stewart R C Hsu-Lin S DeLosky R J Astor B C Fox C H Vassalotti J A (2014) Primary care detection of chronic kidney disease in adults with type 2 diabetes The ADD-CKD Study (Awareness Detection and Drug Therapy in type 2 diabetes and chronic kidney disease PLOS doihttpsdoiorg101371journalpone0110535
bull USRDS (2016) Annual data report 2016 Epidemiology of kidney disease in the United States Retrieved from United States Renal Data System httpswwwusrdsorgadraspx
bull Vasudev B amp Vasudev M (2012) A model curriculum for residents rotating in nephrology MedEDPORTAL doihttpdoiorg1015766mep_2374-82658288
bull Wei L MacDonald T M Jennings C Sheng X amp Flynn R W (2013) Estimated GFR reporting is associated with decreased nonsteroidal anti-inflammatory drug prescribing and increased renal function Kidney International (84)1 174-178
chronic kidney disease in primary care
CKD as a Public Health Issue
Slide Number 3
Costs of CKD in 2013 dollarsUSRDS report
Steps to CKD Patient Care
Renal anatomy and physiology
Definition of Chronic Kidney Disease
CKD Risk Factors
Gaps in CKD Diagnosis
Slide Number 10
Steps to CKD Patient Care
creatinine
Glomerular filtration rate
Slide Number 14
Slide Number 15
Use These Equations Cautiously if at all in hellip
lab albumin creatinine ratio
The New CKD Categories
Steps to CKD Patient Care
Slide Number 20
Kidney Involvement in Systemic Diseases
Slide Number 22
Slide Number 23
DysmorphicRenal Hematuria
Slide Number 25
If you have albuminuria or hematuria-order the following labs
Prevalence of Abnormalities of Mineral Metabolism PTH in CKD
Managing CKD-MBD complications
CKD-MBD Testing
Anemia Becomes More Common as Kidney Function Declines
Detect and Manage CKD Complications
Complications-metabolic acidosis
Complications-vascular calcification
Hyperkalemia management
Hyperuricemia levels amp CKD
CKD monitoring levels 345
Slide Number 59
When to Refer to a Nephrologist
When to Refer
Steps to CKD Patient Care
Kidney transplantation
Starting Dialysis in the ElderlyhellipOr Not
Ckd management
Case 1
Slide Number 67
Lab results
Slide Number 69
Hypertensive nephropathy with proteinuria
Slide Number 71
Case 2
Slide Number 73
Management of CKD in Diabetes
Case 3
Case 3
Systemic Lupus Erythematosus (SLE)
SLE ndash Lupus Nephritis
Case 5
Case 5
Slide Number 81
Slide Number 82
Case study
Slide Number 84
CXR ndash Hilar Lymphadenopathy
Whats needed next
Slide Number 87
newly dx ckd
Slide Number 89
Bibliography
bibliography
bibliography
bibliography
bibliography
WHEN TO REFER TO A NEPHROLOGIST
bull CKD stages 3-5
bull Progression of disease ndash declining eGFR increasing proteinuria
bull Degree of proteinuria nephrotic syndrome gt 05-10 gd on ACEi or ARB therapy
bull Etiology of CKD not certain
bull Need help with disease management
bull Indications for kidney biopsy
Rosenberg 2016
WHEN TO REFER
STEPS TO CKD PATIENT CARE
1 CKD definition and risks2 Assess GFR albuminuria3 Determine etiology4 Assess for evidence of progression5 Assess for associated complications6 Discuss dialysistransplantation
KIDNEY TRANSPLANTATION
bull Treatment of choice for ESRDbull Improves quality of lifebull Waiting list time varies-3-5 yearsbull 3 year survival rate after transplantation is 83-94bull Increased risk of cancer
STARTING DIALYSIS IN THE ELDERLYhellipOR NOT
bull Among patients gt 75 yrs with stage 5 CKD who chose to NOT start dialysisbull Overall more likely to die over next 1-2 years bull But if they had ischemic heart disease or other significant comorbidity NO
DIFFERENCE in survival
bull Active disease management and supportive care may be appropriate without starting dialysis in the ill elderly
bull Palliative care does not mean ldquono carerdquo
bull Must have end-of-life discussions
(Murtagh et al 2007)
CKD MANAGEMENTbull Diagnose cause and treat underlying conditionbull Stage per guidelinesbull Slow progression of kidney disease (ACE inhibitors)bull Monitor for complicationsmdashvolume overload hyperkalemia metabolic acidosis
hyperphosphatemia anorexia fatigue htn bone diseasebull Labs cmp cbc phos Vit D 25OH iPTH urine microscopy uric acid urine
proteincr ratio-frequency based off heat map Get sono at least oncebull Vaccinate influenza hep B pneumococcalbull Eval ASCVD risk-likely needs statinbull Possible dexa (donrsquot give bisphosphonates if GFRlt35 let specialist manage)bull Refer to nephrology when eGFR is lt30 (sometimes if higher risk-refer earlier)
CASE 1
bull 55 year old man with past medical history of headaches presents to your office for his first time visit to a PCP in over 30 years
bull He has no past history of being admitted to the hospital and he does not take any OTC medsNSAIDsherbal meds He has no history of ETOH abuse smoking or drug use
bull Vitals BP 180100 mmHg pulse 80 R 18
bull Exam No JVD S1S2 regular PMI shifted to the left no gallop no abdominal bruit pulses bilaterally equal and regular no leg edema
bull What would you order
bull EKG cbc cmp ua urine proteincr ratio lipid
LAB RESULTS
bull Labs reveal a creatinine of 22 mgdL eGFR 33 Urine shows no blood or casts Urineprotein ratio shows 1 gm protein24 hrs EKG shows LVH
bull Next step in workupbull Renal ultrasound 1st then SPEP UPEP with immunofixation serum free light chains
bull Additional labs neg Renal ultrasound shows that both kidneys are slightly reduced in size and are mildly echogenic with no mass or hydronephrosis
bull What is your diagnosis
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileMain_complications_of_persistent_high_blood_pressurepngCreative Commons License associated httpcreativecommonsorglicensesby-sa30
bull 3 months Howevermdashwe have evidence of structural abnormalities Could potentially stage at G3b A3 (red on the heat map)
bull Goal blood pressure
bull JNC 8 14090 NKF 13080
bull Additional lab needed for progression monitoring
bull Cbc renal panel phos Vit D iPTH uric acid urine micro (we already have the renal sono and urine proteincr ratio and lipid)
Selective renal angiography (left lower renal artery) after successful percutaneous balloon dilatation of the stenotic lesionFibromuscular dysplasia in an accessory renal artery causing renovascular hypertension
Secondary Hypertension
Images retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileRenal_FMD2jpg and httpcommonswikimediaorgwikiFileRenal_FMDjpgCreative Commons License associated httpcreativecommonsorglicensesby20deeden (both images)
CASE 2bull OS is a 64year old Hispanic female in for DM check She has had DM for 15+ years and is currently
taking metformin 1000mg bid Lisinopril 10mg a day atorvastatin 40mg a day Labs today showed the following
bull Hgba1c 86 cmp eGFR 50 lipid WNL proteincr ratio 650mg These results are similar to her last visit
bull Upon further hx-you find that she had a recent eye exam and has mild nonproliferaive retinopathy She does not have neuropathy or other ss
bull What further workup do you need
bull Renal sonogram urine micro iPTH vit D (25 OH) phos uric acid
bull Dx stage
bull G3a A3
bull What further treatment do you need
bull Improve glycemic control Increase Lisinopril to 20mg with a goal of 40mg Avoid NSAIDs or other nephrotoxic agents make sure meds are renally dosed monitor 3xyear nephro referral
MANAGEMENT OF CKD IN DIABETESeGFR Recommended
All patients
Yearly measurement of creatinine urinary albumin excretion potassium
45-60 Referral to a nephrologist if possibility for nondiabetickidney disease existsConsider dose adjustment of medicationsMonitor eGFR every 6 monthsMonitor electrolytes bicarbonate hemoglobin calcium phosphorus parathyroid hormone at least yearly
Assure vitamin D sufficiencyConsider bone density testingReferral for dietary counselling
American Diabetes Association Standards of Medical Care in Diabetes Microvascular complications and foot care Diabetes Care 2017 40 (Suppl 1) S88-S98
CASE 3
bull 19 year old African American woman presents to your clinic with complaints of fatigue joint pains a new rash on her face oral ulcer
bull On exam BP 15080 P 88 Afebrile 96 O2 sats on RAbull GEN No respiratory distress at restbull HEENT painless oral ulcer flat rash over malar eminences sparing the nasolabial fold pallor +bull Lungs CTAbull CVS S1S2 regularbull Abdomen soft NTbull Ext left elbow joint and bilateral wrist joints are swollen and tender
bull What would you orderbull CBC CMP ua urine microscopy (microalbumin or urine proteincr ratio) ANA esr RF anti-ccp uric acid TSH
CASE 3
bull Working dx fatigue oral ulcer joint pain
bull Basic Labs Na 135 K 55 Bicarb 18 BUN 50 Cr 35 eGFR 22 Ca 90 ANA + titer 1640
bull UA 3+ blood 3+ protein RBC casts +
bull Given these results what is the most likely diagnosis
bull What would you do
SYSTEMIC LUPUS ERYTHEMATOSUS (SLE)
bull SLE multisystemic disease Etiology unknown
bull Production of autoantibodies and immune complexes formation
bull There is renal involvement in the great majority of patients with SLE at some time of the evolution 66-90
SLE ndash LUPUS NEPHRITIS
bull Race SLE is more commonsevere in African americans than Caucasiansbull
bull Gender female-to-male ratio of 91
bull Age Most patients develop lupus nephritis early in their disease course SLE is more common among women in the third decade of life and lupus nephritis occurs in patients aged 20-40 years
bull Kidney Biopsy For staging lupus nephritis (Class 1-5)
CASE 5bull A 80 year old man who has not seen a PCP in many years
presents to your clinic for weakness for the past few months On further questioning he tells you that his bones also have been hurting lately and he has developed leg swelling in the past month or so
bull On exam bull BP 16090 P 88 Afebrilebull GEN Thin built manbull HEENT pallor presentbull Lungs clearbull CVS S1S2 regular no rub or gallopbull Abdomen soft NTbull Ext 2 + edema
CASE 5
bull Differentials
bull CHF MI Cancer arthritis
bull Labs
bull CBC CMP urine microscopy urine proteincr ratio ESR TSH EKG BNP pa and lat CXR
bull LABS Urine dipstick negative for protein or blood
bull Basic chem bull Na 136 (135-145) K 51 (35-55) Chloride 108 (96-106) Bicarb 25
Given this presentation and the labs (low anion gap and elevated calcium anemia kidney failure) what will you think of What will you order next
Serum and urine protein electrophoresis
Intratubular refractile casts with surrounding syncytial giant cell reaction with chronic tubulointerstitial nephritis and fibrosis characteristic of myeloma cast nephropathy
Kidney Biopsy
CASE STUDYbull A 35 year old African American woman was seen in the clinic for
chronic cough and dyspnea on exertion She gave history of vague symptoms of fatigue and weight loss of 20 Ibs over the last six months
bull List some differentialsbull TB sarcoid lupus thyroid problems PEbull What would you orderbull PPD cbc cmp UA TSH ANA pa and lat cxr
bull Her labs were significant for mildly elevated calcium level and a creatinine of 20 mgdL eGFR 37
bull She had 750 mg of proteinuriaday
bull PPD neg ANA neg TSH and other labs WNL
bull Assuming this is present more than 3 monthshelliphellipwhat is her ckd stage
bull G3b A3
bull What do we still need
CT scan of chest
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileAnterior_mediastinal_mass_thymomajpgCreative Commons License associated httpcreativecommonsorglicensesby20deeden
CXR ndash HILAR LYMPHADENOPATHY
WHATS NEEDED NEXT
bull Biopsy of hilar lymphadenopathy or renal biopsy
bull DX sarcoidosis
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileSarcoidosis_signs_and_symptomsjpgThis work is in the public domain in the United States because it is a work of the United States Federal Government under the terms of Title 17 Chapter 1 Section 105 of the US Code
NEWLY DX CKD
bull 1) urinalysis microscopy ultrasound proteincr ratio
bull If obstruction-treat
bull No obstruction
bull Hx critical (consider myeloma if high risk)
bull glomerular bleeding or albumin in urine
bull Yes workup for glomerular causes (ANArf hep B C upep spep ANCA complement C3 C4)
bull No sterile pyruria-consider interstitial nephritis
bull High risk renovascular disease Evaluate renovascular disease
Additional Online Resources for CKD LearningbullNational Kidney Foundation wwwkidneyorgbullUnited States Renal Data Service wwwusrdsorgbullCDCrsquos CKD Surveillance Project
httpnccdcdcgovckdbullNational Kidney Disease Education Program
(NKDEP) httpnkdepnihgov
BIBLIOGRAPHY
bull Afzali B amp Goldsmith D J (2016 June 29) Statins and chronic kidney disease (G C Curhan amp A M Sheridan Eds) Retrieved 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsstatins-and-chronic-kidney-disease
bull American Diabetes Association Standards of Medical Care in Diabetes (2017) Microvascular complications and foot care Diabetes Care 2017 (40) S88-S98
bull American Diabetes Association Standards of Medical Care in Diabetes (2017) Microvascular complications and foot care Diabetes Care 40 (suppl 1) S88-S98
bull Berns J S (2017 Mar 22) Treatment of anemia in nondialysis chronic kidney disease (T A Golper amp A M Sheridan Eds) Retrieved from UpToDate httpswww-uptodate-comproxywichitaeducontentstreatment-of-anemia-in-nondialysis-chronic-kidney-disease
bull Chan M Dall A T Fletcher K E Lu N amp Trivedi H (2007) Outcomes in patients with chronic kidney disease referred late to nephrologists a meta-analysis American Journal of Medicine 120(12) 1063-1070
bull Coresh J Selvin E amp Stevens L A (2007) Prevalence of chronic kidny disease in the United States JAMA 298(17) doi101001jama298172038
bull de Brito-Ashurst I Varagunam M Raftery M amp Yagoob M (2009) Bicarbonate supplementation slows progression of CKD and improves nutritional status Journal of American Society of Nephrology (20) 2075-2084
BIBLIOGRAPHY
bull Duncan L Heathcoat J Djurdjev O amp Levin A (2001) Screening for renal disease using serum creatinine who are we missing Nephrology Dialysis and Transplant 16(5) 1042-1046
bull Dunkler D Gao P Lee S F Heinz G Clase C M Tobe S Oberbauer R (2015 August 7) Risk prediction for early CKD in type 2 diabetes Retrieved from Clinical Journal of the American Society of Nephrology httpcjasnasnjournalsorgcontent1081371fullsid=61422554-a5f1-41ac-b696-dcd3b12bd268
bull Fatehi P amp Chi-yuan H (September 15 2016) Diagnostic approach to the patient with newly identified chronic kidney disease (G C Curhan amp A M Sheridan Eds) Retrieved May 7 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsdiagnostic-approach-to-the-patient-with-newly-identified-chronic-kidney-disease
bull Fink J e (2009) Chronic Kidney Disease as an Under-Recognized Threat to Patient Safety American journal of kidney diseases the official journal of the National Kidney Foundation 53(4) 681-688
bull Gaffo A L amp Saag K G (2008 Nov) Management of hyperuricemia and gout in CKD doihttpdxdoiorg101053jajkd200807035
bull Hebert L A amp Parikh S V (2014 June 18) Differential diagnosis and evaluation of glomerular disease (R J Glassock amp A Q Lam Eds) Retrieved May 7 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsdifferential-diagnosis-and-evaluation-of-glomerular-disease
bull Inker L Perrone R D Sterns R H amp Forman J P (2017 March 7) Assessment of kidney function Retrieved from UpToDate httpswww-uptodate-comproxywichitaeducontentsassessment-of-kidney-functionsource=search_resultampsearch=creatinineampselectedTitle=1~150
BIBLIOGRAPHY
bull James P A Ortiz E amp Et Al (2014) Evidence based guideline for the management of high blood pressure in adults (JNC) JAMA 311(5) 507-520
bull Kidney Disease Improving Global Outcomes (KDIGO) CKD Work Group (2013 January) KDIGO 2012 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease Retrieved from Kidney International Supplement httpwwwkidney-internationalorg
bull Kunz R Friedrich C Wolbers M amp Mann J F (2008) Meta-analysis effect of monotherapy and combination therapy with inhibitors of the renin angiotensin system on proteinuria in renal disease Annals of Internal Medicine 148(1) 30-48
bull Levey A Stevens L A Schmid C H Castro A F Feldman H I Kusek J W Coresh J (2009) A new equation to estimate glomerular filtration rate Annals of Internal Medicine 150(9) 604-612
bull Levin A Bakris G L Molitch M Smulders M M Williams L A amp Andress D L (2007 Jan) Prevalence of abnormal serum vitamin D PTH calcium and phosphorus in patients with chronic kidney disease results of the study to evaluate early kidney disease Kidney International 71(1) 31-38 Retrieved from PubMED
bull Mahajan A Simoni J Sheather S Broglio K Rajab M amp Wesson D (2010) Daily oral sodium bicarbonate preserves glomerular filtration rate by slowing its decline in early hypertensive nephropathy Kidney International (78_ 303-309
bull Mann J Schmieder R E amp McQueen M (2008) Renal outcomes with telmisartan ramipril or both in people at high vascular risk (the ONTARGET study) a multicentre randomised doubleblind ocntrolled trial Lancet 372(9638) 547-533
BIBLIOGRAPHY
bull Matovinović M S (2009) Pathophysiology and classification of kidney disease Retrieved from The Journal of the International Federation of Clinical Chemistry and Laboratory Medicine httpwwwifccorgifccfilesdocs20010902pdf
bull Moe S Drueke T Lameire N amp Eknoyan G (2007 Jan) Chronic kidney disease-mineral-bone disorder a new paradigmdoi101053jackd200610005
bull Murtagh F E Marsh J E Donohoe P Ekbal N J Sheerin N S amp Harris F E (2007 July) Dialysis or not A comparative survival study of patients over 75 years with chronic kidney disease stage 5 Retrieved from Nephrology Dialysis and Transplant 22(7) httpswwwncbinlmnihgovpubmed17412702
bull National Kidney Foundation (2002) KDOQI clinical practice guidelines for chronic kidney disease evaluation classification andstratification American Journal of Kidney Disease S1-S266
bull National Kidney Foundation (2014 November 5) Fact Sheets Retrieved from httpwwwkidneyorgnewsnewsroomfactsheetsFastFacts
bull Pal S (2012 June 2) Trends in chronic kidney disease Retrieved from US Pharmacist (37)6 httpswwwuspharmacistcomarticletrends-in-chronic-kidney-disease
bull Qunibi W amp Henrich W L (2017 Jan 19) Overview of chronic kidney disease-mineral and bone disorder (J Berns amp A M Sheridan Eds) Retrieved from UpToDate httpswww-uptodate-comoverview-of-chronic-kidney-disease-mineral-and-bone-disorder-ckd-mbd
bull Rosenberg M (2016 Feb 24) Overview of the management of chronic kidney disease in adults (G C Curhan amp A M Sheridan Eds) Retrieved from UpToDate UpToDate httpswww-uptodate-comproxywichitaeducontentsoverview-of-the-management-of-chronic-kidney-disease-in-adults
BIBLIOGRAPHY
bull Szczech L Stewart R C Hsu-Lin S DeLosky R J Astor B C Fox C H Vassalotti J A (2014) Primary care detection of chronic kidney disease in adults with type 2 diabetes The ADD-CKD Study (Awareness Detection and Drug Therapy in type 2 diabetes and chronic kidney disease PLOS doihttpsdoiorg101371journalpone0110535
bull USRDS (2016) Annual data report 2016 Epidemiology of kidney disease in the United States Retrieved from United States Renal Data System httpswwwusrdsorgadraspx
bull Vasudev B amp Vasudev M (2012) A model curriculum for residents rotating in nephrology MedEDPORTAL doihttpdoiorg1015766mep_2374-82658288
bull Wei L MacDonald T M Jennings C Sheng X amp Flynn R W (2013) Estimated GFR reporting is associated with decreased nonsteroidal anti-inflammatory drug prescribing and increased renal function Kidney International (84)1 174-178
chronic kidney disease in primary care
CKD as a Public Health Issue
Slide Number 3
Costs of CKD in 2013 dollarsUSRDS report
Steps to CKD Patient Care
Renal anatomy and physiology
Definition of Chronic Kidney Disease
CKD Risk Factors
Gaps in CKD Diagnosis
Slide Number 10
Steps to CKD Patient Care
creatinine
Glomerular filtration rate
Slide Number 14
Slide Number 15
Use These Equations Cautiously if at all in hellip
lab albumin creatinine ratio
The New CKD Categories
Steps to CKD Patient Care
Slide Number 20
Kidney Involvement in Systemic Diseases
Slide Number 22
Slide Number 23
DysmorphicRenal Hematuria
Slide Number 25
If you have albuminuria or hematuria-order the following labs
Prevalence of Abnormalities of Mineral Metabolism PTH in CKD
Managing CKD-MBD complications
CKD-MBD Testing
Anemia Becomes More Common as Kidney Function Declines
Detect and Manage CKD Complications
Complications-metabolic acidosis
Complications-vascular calcification
Hyperkalemia management
Hyperuricemia levels amp CKD
CKD monitoring levels 345
Slide Number 59
When to Refer to a Nephrologist
When to Refer
Steps to CKD Patient Care
Kidney transplantation
Starting Dialysis in the ElderlyhellipOr Not
Ckd management
Case 1
Slide Number 67
Lab results
Slide Number 69
Hypertensive nephropathy with proteinuria
Slide Number 71
Case 2
Slide Number 73
Management of CKD in Diabetes
Case 3
Case 3
Systemic Lupus Erythematosus (SLE)
SLE ndash Lupus Nephritis
Case 5
Case 5
Slide Number 81
Slide Number 82
Case study
Slide Number 84
CXR ndash Hilar Lymphadenopathy
Whats needed next
Slide Number 87
newly dx ckd
Slide Number 89
Bibliography
bibliography
bibliography
bibliography
bibliography
WHEN TO REFER
STEPS TO CKD PATIENT CARE
1 CKD definition and risks2 Assess GFR albuminuria3 Determine etiology4 Assess for evidence of progression5 Assess for associated complications6 Discuss dialysistransplantation
KIDNEY TRANSPLANTATION
bull Treatment of choice for ESRDbull Improves quality of lifebull Waiting list time varies-3-5 yearsbull 3 year survival rate after transplantation is 83-94bull Increased risk of cancer
STARTING DIALYSIS IN THE ELDERLYhellipOR NOT
bull Among patients gt 75 yrs with stage 5 CKD who chose to NOT start dialysisbull Overall more likely to die over next 1-2 years bull But if they had ischemic heart disease or other significant comorbidity NO
DIFFERENCE in survival
bull Active disease management and supportive care may be appropriate without starting dialysis in the ill elderly
bull Palliative care does not mean ldquono carerdquo
bull Must have end-of-life discussions
(Murtagh et al 2007)
CKD MANAGEMENTbull Diagnose cause and treat underlying conditionbull Stage per guidelinesbull Slow progression of kidney disease (ACE inhibitors)bull Monitor for complicationsmdashvolume overload hyperkalemia metabolic acidosis
hyperphosphatemia anorexia fatigue htn bone diseasebull Labs cmp cbc phos Vit D 25OH iPTH urine microscopy uric acid urine
proteincr ratio-frequency based off heat map Get sono at least oncebull Vaccinate influenza hep B pneumococcalbull Eval ASCVD risk-likely needs statinbull Possible dexa (donrsquot give bisphosphonates if GFRlt35 let specialist manage)bull Refer to nephrology when eGFR is lt30 (sometimes if higher risk-refer earlier)
CASE 1
bull 55 year old man with past medical history of headaches presents to your office for his first time visit to a PCP in over 30 years
bull He has no past history of being admitted to the hospital and he does not take any OTC medsNSAIDsherbal meds He has no history of ETOH abuse smoking or drug use
bull Vitals BP 180100 mmHg pulse 80 R 18
bull Exam No JVD S1S2 regular PMI shifted to the left no gallop no abdominal bruit pulses bilaterally equal and regular no leg edema
bull What would you order
bull EKG cbc cmp ua urine proteincr ratio lipid
LAB RESULTS
bull Labs reveal a creatinine of 22 mgdL eGFR 33 Urine shows no blood or casts Urineprotein ratio shows 1 gm protein24 hrs EKG shows LVH
bull Next step in workupbull Renal ultrasound 1st then SPEP UPEP with immunofixation serum free light chains
bull Additional labs neg Renal ultrasound shows that both kidneys are slightly reduced in size and are mildly echogenic with no mass or hydronephrosis
bull What is your diagnosis
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileMain_complications_of_persistent_high_blood_pressurepngCreative Commons License associated httpcreativecommonsorglicensesby-sa30
bull 3 months Howevermdashwe have evidence of structural abnormalities Could potentially stage at G3b A3 (red on the heat map)
bull Goal blood pressure
bull JNC 8 14090 NKF 13080
bull Additional lab needed for progression monitoring
bull Cbc renal panel phos Vit D iPTH uric acid urine micro (we already have the renal sono and urine proteincr ratio and lipid)
Selective renal angiography (left lower renal artery) after successful percutaneous balloon dilatation of the stenotic lesionFibromuscular dysplasia in an accessory renal artery causing renovascular hypertension
Secondary Hypertension
Images retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileRenal_FMD2jpg and httpcommonswikimediaorgwikiFileRenal_FMDjpgCreative Commons License associated httpcreativecommonsorglicensesby20deeden (both images)
CASE 2bull OS is a 64year old Hispanic female in for DM check She has had DM for 15+ years and is currently
taking metformin 1000mg bid Lisinopril 10mg a day atorvastatin 40mg a day Labs today showed the following
bull Hgba1c 86 cmp eGFR 50 lipid WNL proteincr ratio 650mg These results are similar to her last visit
bull Upon further hx-you find that she had a recent eye exam and has mild nonproliferaive retinopathy She does not have neuropathy or other ss
bull What further workup do you need
bull Renal sonogram urine micro iPTH vit D (25 OH) phos uric acid
bull Dx stage
bull G3a A3
bull What further treatment do you need
bull Improve glycemic control Increase Lisinopril to 20mg with a goal of 40mg Avoid NSAIDs or other nephrotoxic agents make sure meds are renally dosed monitor 3xyear nephro referral
MANAGEMENT OF CKD IN DIABETESeGFR Recommended
All patients
Yearly measurement of creatinine urinary albumin excretion potassium
45-60 Referral to a nephrologist if possibility for nondiabetickidney disease existsConsider dose adjustment of medicationsMonitor eGFR every 6 monthsMonitor electrolytes bicarbonate hemoglobin calcium phosphorus parathyroid hormone at least yearly
Assure vitamin D sufficiencyConsider bone density testingReferral for dietary counselling
American Diabetes Association Standards of Medical Care in Diabetes Microvascular complications and foot care Diabetes Care 2017 40 (Suppl 1) S88-S98
CASE 3
bull 19 year old African American woman presents to your clinic with complaints of fatigue joint pains a new rash on her face oral ulcer
bull On exam BP 15080 P 88 Afebrile 96 O2 sats on RAbull GEN No respiratory distress at restbull HEENT painless oral ulcer flat rash over malar eminences sparing the nasolabial fold pallor +bull Lungs CTAbull CVS S1S2 regularbull Abdomen soft NTbull Ext left elbow joint and bilateral wrist joints are swollen and tender
bull What would you orderbull CBC CMP ua urine microscopy (microalbumin or urine proteincr ratio) ANA esr RF anti-ccp uric acid TSH
CASE 3
bull Working dx fatigue oral ulcer joint pain
bull Basic Labs Na 135 K 55 Bicarb 18 BUN 50 Cr 35 eGFR 22 Ca 90 ANA + titer 1640
bull UA 3+ blood 3+ protein RBC casts +
bull Given these results what is the most likely diagnosis
bull What would you do
SYSTEMIC LUPUS ERYTHEMATOSUS (SLE)
bull SLE multisystemic disease Etiology unknown
bull Production of autoantibodies and immune complexes formation
bull There is renal involvement in the great majority of patients with SLE at some time of the evolution 66-90
SLE ndash LUPUS NEPHRITIS
bull Race SLE is more commonsevere in African americans than Caucasiansbull
bull Gender female-to-male ratio of 91
bull Age Most patients develop lupus nephritis early in their disease course SLE is more common among women in the third decade of life and lupus nephritis occurs in patients aged 20-40 years
bull Kidney Biopsy For staging lupus nephritis (Class 1-5)
CASE 5bull A 80 year old man who has not seen a PCP in many years
presents to your clinic for weakness for the past few months On further questioning he tells you that his bones also have been hurting lately and he has developed leg swelling in the past month or so
bull On exam bull BP 16090 P 88 Afebrilebull GEN Thin built manbull HEENT pallor presentbull Lungs clearbull CVS S1S2 regular no rub or gallopbull Abdomen soft NTbull Ext 2 + edema
CASE 5
bull Differentials
bull CHF MI Cancer arthritis
bull Labs
bull CBC CMP urine microscopy urine proteincr ratio ESR TSH EKG BNP pa and lat CXR
bull LABS Urine dipstick negative for protein or blood
bull Basic chem bull Na 136 (135-145) K 51 (35-55) Chloride 108 (96-106) Bicarb 25
Given this presentation and the labs (low anion gap and elevated calcium anemia kidney failure) what will you think of What will you order next
Serum and urine protein electrophoresis
Intratubular refractile casts with surrounding syncytial giant cell reaction with chronic tubulointerstitial nephritis and fibrosis characteristic of myeloma cast nephropathy
Kidney Biopsy
CASE STUDYbull A 35 year old African American woman was seen in the clinic for
chronic cough and dyspnea on exertion She gave history of vague symptoms of fatigue and weight loss of 20 Ibs over the last six months
bull List some differentialsbull TB sarcoid lupus thyroid problems PEbull What would you orderbull PPD cbc cmp UA TSH ANA pa and lat cxr
bull Her labs were significant for mildly elevated calcium level and a creatinine of 20 mgdL eGFR 37
bull She had 750 mg of proteinuriaday
bull PPD neg ANA neg TSH and other labs WNL
bull Assuming this is present more than 3 monthshelliphellipwhat is her ckd stage
bull G3b A3
bull What do we still need
CT scan of chest
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileAnterior_mediastinal_mass_thymomajpgCreative Commons License associated httpcreativecommonsorglicensesby20deeden
CXR ndash HILAR LYMPHADENOPATHY
WHATS NEEDED NEXT
bull Biopsy of hilar lymphadenopathy or renal biopsy
bull DX sarcoidosis
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileSarcoidosis_signs_and_symptomsjpgThis work is in the public domain in the United States because it is a work of the United States Federal Government under the terms of Title 17 Chapter 1 Section 105 of the US Code
NEWLY DX CKD
bull 1) urinalysis microscopy ultrasound proteincr ratio
bull If obstruction-treat
bull No obstruction
bull Hx critical (consider myeloma if high risk)
bull glomerular bleeding or albumin in urine
bull Yes workup for glomerular causes (ANArf hep B C upep spep ANCA complement C3 C4)
bull No sterile pyruria-consider interstitial nephritis
bull High risk renovascular disease Evaluate renovascular disease
Additional Online Resources for CKD LearningbullNational Kidney Foundation wwwkidneyorgbullUnited States Renal Data Service wwwusrdsorgbullCDCrsquos CKD Surveillance Project
httpnccdcdcgovckdbullNational Kidney Disease Education Program
(NKDEP) httpnkdepnihgov
BIBLIOGRAPHY
bull Afzali B amp Goldsmith D J (2016 June 29) Statins and chronic kidney disease (G C Curhan amp A M Sheridan Eds) Retrieved 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsstatins-and-chronic-kidney-disease
bull American Diabetes Association Standards of Medical Care in Diabetes (2017) Microvascular complications and foot care Diabetes Care 2017 (40) S88-S98
bull American Diabetes Association Standards of Medical Care in Diabetes (2017) Microvascular complications and foot care Diabetes Care 40 (suppl 1) S88-S98
bull Berns J S (2017 Mar 22) Treatment of anemia in nondialysis chronic kidney disease (T A Golper amp A M Sheridan Eds) Retrieved from UpToDate httpswww-uptodate-comproxywichitaeducontentstreatment-of-anemia-in-nondialysis-chronic-kidney-disease
bull Chan M Dall A T Fletcher K E Lu N amp Trivedi H (2007) Outcomes in patients with chronic kidney disease referred late to nephrologists a meta-analysis American Journal of Medicine 120(12) 1063-1070
bull Coresh J Selvin E amp Stevens L A (2007) Prevalence of chronic kidny disease in the United States JAMA 298(17) doi101001jama298172038
bull de Brito-Ashurst I Varagunam M Raftery M amp Yagoob M (2009) Bicarbonate supplementation slows progression of CKD and improves nutritional status Journal of American Society of Nephrology (20) 2075-2084
BIBLIOGRAPHY
bull Duncan L Heathcoat J Djurdjev O amp Levin A (2001) Screening for renal disease using serum creatinine who are we missing Nephrology Dialysis and Transplant 16(5) 1042-1046
bull Dunkler D Gao P Lee S F Heinz G Clase C M Tobe S Oberbauer R (2015 August 7) Risk prediction for early CKD in type 2 diabetes Retrieved from Clinical Journal of the American Society of Nephrology httpcjasnasnjournalsorgcontent1081371fullsid=61422554-a5f1-41ac-b696-dcd3b12bd268
bull Fatehi P amp Chi-yuan H (September 15 2016) Diagnostic approach to the patient with newly identified chronic kidney disease (G C Curhan amp A M Sheridan Eds) Retrieved May 7 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsdiagnostic-approach-to-the-patient-with-newly-identified-chronic-kidney-disease
bull Fink J e (2009) Chronic Kidney Disease as an Under-Recognized Threat to Patient Safety American journal of kidney diseases the official journal of the National Kidney Foundation 53(4) 681-688
bull Gaffo A L amp Saag K G (2008 Nov) Management of hyperuricemia and gout in CKD doihttpdxdoiorg101053jajkd200807035
bull Hebert L A amp Parikh S V (2014 June 18) Differential diagnosis and evaluation of glomerular disease (R J Glassock amp A Q Lam Eds) Retrieved May 7 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsdifferential-diagnosis-and-evaluation-of-glomerular-disease
bull Inker L Perrone R D Sterns R H amp Forman J P (2017 March 7) Assessment of kidney function Retrieved from UpToDate httpswww-uptodate-comproxywichitaeducontentsassessment-of-kidney-functionsource=search_resultampsearch=creatinineampselectedTitle=1~150
BIBLIOGRAPHY
bull James P A Ortiz E amp Et Al (2014) Evidence based guideline for the management of high blood pressure in adults (JNC) JAMA 311(5) 507-520
bull Kidney Disease Improving Global Outcomes (KDIGO) CKD Work Group (2013 January) KDIGO 2012 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease Retrieved from Kidney International Supplement httpwwwkidney-internationalorg
bull Kunz R Friedrich C Wolbers M amp Mann J F (2008) Meta-analysis effect of monotherapy and combination therapy with inhibitors of the renin angiotensin system on proteinuria in renal disease Annals of Internal Medicine 148(1) 30-48
bull Levey A Stevens L A Schmid C H Castro A F Feldman H I Kusek J W Coresh J (2009) A new equation to estimate glomerular filtration rate Annals of Internal Medicine 150(9) 604-612
bull Levin A Bakris G L Molitch M Smulders M M Williams L A amp Andress D L (2007 Jan) Prevalence of abnormal serum vitamin D PTH calcium and phosphorus in patients with chronic kidney disease results of the study to evaluate early kidney disease Kidney International 71(1) 31-38 Retrieved from PubMED
bull Mahajan A Simoni J Sheather S Broglio K Rajab M amp Wesson D (2010) Daily oral sodium bicarbonate preserves glomerular filtration rate by slowing its decline in early hypertensive nephropathy Kidney International (78_ 303-309
bull Mann J Schmieder R E amp McQueen M (2008) Renal outcomes with telmisartan ramipril or both in people at high vascular risk (the ONTARGET study) a multicentre randomised doubleblind ocntrolled trial Lancet 372(9638) 547-533
BIBLIOGRAPHY
bull Matovinović M S (2009) Pathophysiology and classification of kidney disease Retrieved from The Journal of the International Federation of Clinical Chemistry and Laboratory Medicine httpwwwifccorgifccfilesdocs20010902pdf
bull Moe S Drueke T Lameire N amp Eknoyan G (2007 Jan) Chronic kidney disease-mineral-bone disorder a new paradigmdoi101053jackd200610005
bull Murtagh F E Marsh J E Donohoe P Ekbal N J Sheerin N S amp Harris F E (2007 July) Dialysis or not A comparative survival study of patients over 75 years with chronic kidney disease stage 5 Retrieved from Nephrology Dialysis and Transplant 22(7) httpswwwncbinlmnihgovpubmed17412702
bull National Kidney Foundation (2002) KDOQI clinical practice guidelines for chronic kidney disease evaluation classification andstratification American Journal of Kidney Disease S1-S266
bull National Kidney Foundation (2014 November 5) Fact Sheets Retrieved from httpwwwkidneyorgnewsnewsroomfactsheetsFastFacts
bull Pal S (2012 June 2) Trends in chronic kidney disease Retrieved from US Pharmacist (37)6 httpswwwuspharmacistcomarticletrends-in-chronic-kidney-disease
bull Qunibi W amp Henrich W L (2017 Jan 19) Overview of chronic kidney disease-mineral and bone disorder (J Berns amp A M Sheridan Eds) Retrieved from UpToDate httpswww-uptodate-comoverview-of-chronic-kidney-disease-mineral-and-bone-disorder-ckd-mbd
bull Rosenberg M (2016 Feb 24) Overview of the management of chronic kidney disease in adults (G C Curhan amp A M Sheridan Eds) Retrieved from UpToDate UpToDate httpswww-uptodate-comproxywichitaeducontentsoverview-of-the-management-of-chronic-kidney-disease-in-adults
BIBLIOGRAPHY
bull Szczech L Stewart R C Hsu-Lin S DeLosky R J Astor B C Fox C H Vassalotti J A (2014) Primary care detection of chronic kidney disease in adults with type 2 diabetes The ADD-CKD Study (Awareness Detection and Drug Therapy in type 2 diabetes and chronic kidney disease PLOS doihttpsdoiorg101371journalpone0110535
bull USRDS (2016) Annual data report 2016 Epidemiology of kidney disease in the United States Retrieved from United States Renal Data System httpswwwusrdsorgadraspx
bull Vasudev B amp Vasudev M (2012) A model curriculum for residents rotating in nephrology MedEDPORTAL doihttpdoiorg1015766mep_2374-82658288
bull Wei L MacDonald T M Jennings C Sheng X amp Flynn R W (2013) Estimated GFR reporting is associated with decreased nonsteroidal anti-inflammatory drug prescribing and increased renal function Kidney International (84)1 174-178
chronic kidney disease in primary care
CKD as a Public Health Issue
Slide Number 3
Costs of CKD in 2013 dollarsUSRDS report
Steps to CKD Patient Care
Renal anatomy and physiology
Definition of Chronic Kidney Disease
CKD Risk Factors
Gaps in CKD Diagnosis
Slide Number 10
Steps to CKD Patient Care
creatinine
Glomerular filtration rate
Slide Number 14
Slide Number 15
Use These Equations Cautiously if at all in hellip
lab albumin creatinine ratio
The New CKD Categories
Steps to CKD Patient Care
Slide Number 20
Kidney Involvement in Systemic Diseases
Slide Number 22
Slide Number 23
DysmorphicRenal Hematuria
Slide Number 25
If you have albuminuria or hematuria-order the following labs
Prevalence of Abnormalities of Mineral Metabolism PTH in CKD
Managing CKD-MBD complications
CKD-MBD Testing
Anemia Becomes More Common as Kidney Function Declines
Detect and Manage CKD Complications
Complications-metabolic acidosis
Complications-vascular calcification
Hyperkalemia management
Hyperuricemia levels amp CKD
CKD monitoring levels 345
Slide Number 59
When to Refer to a Nephrologist
When to Refer
Steps to CKD Patient Care
Kidney transplantation
Starting Dialysis in the ElderlyhellipOr Not
Ckd management
Case 1
Slide Number 67
Lab results
Slide Number 69
Hypertensive nephropathy with proteinuria
Slide Number 71
Case 2
Slide Number 73
Management of CKD in Diabetes
Case 3
Case 3
Systemic Lupus Erythematosus (SLE)
SLE ndash Lupus Nephritis
Case 5
Case 5
Slide Number 81
Slide Number 82
Case study
Slide Number 84
CXR ndash Hilar Lymphadenopathy
Whats needed next
Slide Number 87
newly dx ckd
Slide Number 89
Bibliography
bibliography
bibliography
bibliography
bibliography
STEPS TO CKD PATIENT CARE
1 CKD definition and risks2 Assess GFR albuminuria3 Determine etiology4 Assess for evidence of progression5 Assess for associated complications6 Discuss dialysistransplantation
KIDNEY TRANSPLANTATION
bull Treatment of choice for ESRDbull Improves quality of lifebull Waiting list time varies-3-5 yearsbull 3 year survival rate after transplantation is 83-94bull Increased risk of cancer
STARTING DIALYSIS IN THE ELDERLYhellipOR NOT
bull Among patients gt 75 yrs with stage 5 CKD who chose to NOT start dialysisbull Overall more likely to die over next 1-2 years bull But if they had ischemic heart disease or other significant comorbidity NO
DIFFERENCE in survival
bull Active disease management and supportive care may be appropriate without starting dialysis in the ill elderly
bull Palliative care does not mean ldquono carerdquo
bull Must have end-of-life discussions
(Murtagh et al 2007)
CKD MANAGEMENTbull Diagnose cause and treat underlying conditionbull Stage per guidelinesbull Slow progression of kidney disease (ACE inhibitors)bull Monitor for complicationsmdashvolume overload hyperkalemia metabolic acidosis
hyperphosphatemia anorexia fatigue htn bone diseasebull Labs cmp cbc phos Vit D 25OH iPTH urine microscopy uric acid urine
proteincr ratio-frequency based off heat map Get sono at least oncebull Vaccinate influenza hep B pneumococcalbull Eval ASCVD risk-likely needs statinbull Possible dexa (donrsquot give bisphosphonates if GFRlt35 let specialist manage)bull Refer to nephrology when eGFR is lt30 (sometimes if higher risk-refer earlier)
CASE 1
bull 55 year old man with past medical history of headaches presents to your office for his first time visit to a PCP in over 30 years
bull He has no past history of being admitted to the hospital and he does not take any OTC medsNSAIDsherbal meds He has no history of ETOH abuse smoking or drug use
bull Vitals BP 180100 mmHg pulse 80 R 18
bull Exam No JVD S1S2 regular PMI shifted to the left no gallop no abdominal bruit pulses bilaterally equal and regular no leg edema
bull What would you order
bull EKG cbc cmp ua urine proteincr ratio lipid
LAB RESULTS
bull Labs reveal a creatinine of 22 mgdL eGFR 33 Urine shows no blood or casts Urineprotein ratio shows 1 gm protein24 hrs EKG shows LVH
bull Next step in workupbull Renal ultrasound 1st then SPEP UPEP with immunofixation serum free light chains
bull Additional labs neg Renal ultrasound shows that both kidneys are slightly reduced in size and are mildly echogenic with no mass or hydronephrosis
bull What is your diagnosis
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileMain_complications_of_persistent_high_blood_pressurepngCreative Commons License associated httpcreativecommonsorglicensesby-sa30
bull 3 months Howevermdashwe have evidence of structural abnormalities Could potentially stage at G3b A3 (red on the heat map)
bull Goal blood pressure
bull JNC 8 14090 NKF 13080
bull Additional lab needed for progression monitoring
bull Cbc renal panel phos Vit D iPTH uric acid urine micro (we already have the renal sono and urine proteincr ratio and lipid)
Selective renal angiography (left lower renal artery) after successful percutaneous balloon dilatation of the stenotic lesionFibromuscular dysplasia in an accessory renal artery causing renovascular hypertension
Secondary Hypertension
Images retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileRenal_FMD2jpg and httpcommonswikimediaorgwikiFileRenal_FMDjpgCreative Commons License associated httpcreativecommonsorglicensesby20deeden (both images)
CASE 2bull OS is a 64year old Hispanic female in for DM check She has had DM for 15+ years and is currently
taking metformin 1000mg bid Lisinopril 10mg a day atorvastatin 40mg a day Labs today showed the following
bull Hgba1c 86 cmp eGFR 50 lipid WNL proteincr ratio 650mg These results are similar to her last visit
bull Upon further hx-you find that she had a recent eye exam and has mild nonproliferaive retinopathy She does not have neuropathy or other ss
bull What further workup do you need
bull Renal sonogram urine micro iPTH vit D (25 OH) phos uric acid
bull Dx stage
bull G3a A3
bull What further treatment do you need
bull Improve glycemic control Increase Lisinopril to 20mg with a goal of 40mg Avoid NSAIDs or other nephrotoxic agents make sure meds are renally dosed monitor 3xyear nephro referral
MANAGEMENT OF CKD IN DIABETESeGFR Recommended
All patients
Yearly measurement of creatinine urinary albumin excretion potassium
45-60 Referral to a nephrologist if possibility for nondiabetickidney disease existsConsider dose adjustment of medicationsMonitor eGFR every 6 monthsMonitor electrolytes bicarbonate hemoglobin calcium phosphorus parathyroid hormone at least yearly
Assure vitamin D sufficiencyConsider bone density testingReferral for dietary counselling
American Diabetes Association Standards of Medical Care in Diabetes Microvascular complications and foot care Diabetes Care 2017 40 (Suppl 1) S88-S98
CASE 3
bull 19 year old African American woman presents to your clinic with complaints of fatigue joint pains a new rash on her face oral ulcer
bull On exam BP 15080 P 88 Afebrile 96 O2 sats on RAbull GEN No respiratory distress at restbull HEENT painless oral ulcer flat rash over malar eminences sparing the nasolabial fold pallor +bull Lungs CTAbull CVS S1S2 regularbull Abdomen soft NTbull Ext left elbow joint and bilateral wrist joints are swollen and tender
bull What would you orderbull CBC CMP ua urine microscopy (microalbumin or urine proteincr ratio) ANA esr RF anti-ccp uric acid TSH
CASE 3
bull Working dx fatigue oral ulcer joint pain
bull Basic Labs Na 135 K 55 Bicarb 18 BUN 50 Cr 35 eGFR 22 Ca 90 ANA + titer 1640
bull UA 3+ blood 3+ protein RBC casts +
bull Given these results what is the most likely diagnosis
bull What would you do
SYSTEMIC LUPUS ERYTHEMATOSUS (SLE)
bull SLE multisystemic disease Etiology unknown
bull Production of autoantibodies and immune complexes formation
bull There is renal involvement in the great majority of patients with SLE at some time of the evolution 66-90
SLE ndash LUPUS NEPHRITIS
bull Race SLE is more commonsevere in African americans than Caucasiansbull
bull Gender female-to-male ratio of 91
bull Age Most patients develop lupus nephritis early in their disease course SLE is more common among women in the third decade of life and lupus nephritis occurs in patients aged 20-40 years
bull Kidney Biopsy For staging lupus nephritis (Class 1-5)
CASE 5bull A 80 year old man who has not seen a PCP in many years
presents to your clinic for weakness for the past few months On further questioning he tells you that his bones also have been hurting lately and he has developed leg swelling in the past month or so
bull On exam bull BP 16090 P 88 Afebrilebull GEN Thin built manbull HEENT pallor presentbull Lungs clearbull CVS S1S2 regular no rub or gallopbull Abdomen soft NTbull Ext 2 + edema
CASE 5
bull Differentials
bull CHF MI Cancer arthritis
bull Labs
bull CBC CMP urine microscopy urine proteincr ratio ESR TSH EKG BNP pa and lat CXR
bull LABS Urine dipstick negative for protein or blood
bull Basic chem bull Na 136 (135-145) K 51 (35-55) Chloride 108 (96-106) Bicarb 25
Given this presentation and the labs (low anion gap and elevated calcium anemia kidney failure) what will you think of What will you order next
Serum and urine protein electrophoresis
Intratubular refractile casts with surrounding syncytial giant cell reaction with chronic tubulointerstitial nephritis and fibrosis characteristic of myeloma cast nephropathy
Kidney Biopsy
CASE STUDYbull A 35 year old African American woman was seen in the clinic for
chronic cough and dyspnea on exertion She gave history of vague symptoms of fatigue and weight loss of 20 Ibs over the last six months
bull List some differentialsbull TB sarcoid lupus thyroid problems PEbull What would you orderbull PPD cbc cmp UA TSH ANA pa and lat cxr
bull Her labs were significant for mildly elevated calcium level and a creatinine of 20 mgdL eGFR 37
bull She had 750 mg of proteinuriaday
bull PPD neg ANA neg TSH and other labs WNL
bull Assuming this is present more than 3 monthshelliphellipwhat is her ckd stage
bull G3b A3
bull What do we still need
CT scan of chest
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileAnterior_mediastinal_mass_thymomajpgCreative Commons License associated httpcreativecommonsorglicensesby20deeden
CXR ndash HILAR LYMPHADENOPATHY
WHATS NEEDED NEXT
bull Biopsy of hilar lymphadenopathy or renal biopsy
bull DX sarcoidosis
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileSarcoidosis_signs_and_symptomsjpgThis work is in the public domain in the United States because it is a work of the United States Federal Government under the terms of Title 17 Chapter 1 Section 105 of the US Code
NEWLY DX CKD
bull 1) urinalysis microscopy ultrasound proteincr ratio
bull If obstruction-treat
bull No obstruction
bull Hx critical (consider myeloma if high risk)
bull glomerular bleeding or albumin in urine
bull Yes workup for glomerular causes (ANArf hep B C upep spep ANCA complement C3 C4)
bull No sterile pyruria-consider interstitial nephritis
bull High risk renovascular disease Evaluate renovascular disease
Additional Online Resources for CKD LearningbullNational Kidney Foundation wwwkidneyorgbullUnited States Renal Data Service wwwusrdsorgbullCDCrsquos CKD Surveillance Project
httpnccdcdcgovckdbullNational Kidney Disease Education Program
(NKDEP) httpnkdepnihgov
BIBLIOGRAPHY
bull Afzali B amp Goldsmith D J (2016 June 29) Statins and chronic kidney disease (G C Curhan amp A M Sheridan Eds) Retrieved 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsstatins-and-chronic-kidney-disease
bull American Diabetes Association Standards of Medical Care in Diabetes (2017) Microvascular complications and foot care Diabetes Care 2017 (40) S88-S98
bull American Diabetes Association Standards of Medical Care in Diabetes (2017) Microvascular complications and foot care Diabetes Care 40 (suppl 1) S88-S98
bull Berns J S (2017 Mar 22) Treatment of anemia in nondialysis chronic kidney disease (T A Golper amp A M Sheridan Eds) Retrieved from UpToDate httpswww-uptodate-comproxywichitaeducontentstreatment-of-anemia-in-nondialysis-chronic-kidney-disease
bull Chan M Dall A T Fletcher K E Lu N amp Trivedi H (2007) Outcomes in patients with chronic kidney disease referred late to nephrologists a meta-analysis American Journal of Medicine 120(12) 1063-1070
bull Coresh J Selvin E amp Stevens L A (2007) Prevalence of chronic kidny disease in the United States JAMA 298(17) doi101001jama298172038
bull de Brito-Ashurst I Varagunam M Raftery M amp Yagoob M (2009) Bicarbonate supplementation slows progression of CKD and improves nutritional status Journal of American Society of Nephrology (20) 2075-2084
BIBLIOGRAPHY
bull Duncan L Heathcoat J Djurdjev O amp Levin A (2001) Screening for renal disease using serum creatinine who are we missing Nephrology Dialysis and Transplant 16(5) 1042-1046
bull Dunkler D Gao P Lee S F Heinz G Clase C M Tobe S Oberbauer R (2015 August 7) Risk prediction for early CKD in type 2 diabetes Retrieved from Clinical Journal of the American Society of Nephrology httpcjasnasnjournalsorgcontent1081371fullsid=61422554-a5f1-41ac-b696-dcd3b12bd268
bull Fatehi P amp Chi-yuan H (September 15 2016) Diagnostic approach to the patient with newly identified chronic kidney disease (G C Curhan amp A M Sheridan Eds) Retrieved May 7 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsdiagnostic-approach-to-the-patient-with-newly-identified-chronic-kidney-disease
bull Fink J e (2009) Chronic Kidney Disease as an Under-Recognized Threat to Patient Safety American journal of kidney diseases the official journal of the National Kidney Foundation 53(4) 681-688
bull Gaffo A L amp Saag K G (2008 Nov) Management of hyperuricemia and gout in CKD doihttpdxdoiorg101053jajkd200807035
bull Hebert L A amp Parikh S V (2014 June 18) Differential diagnosis and evaluation of glomerular disease (R J Glassock amp A Q Lam Eds) Retrieved May 7 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsdifferential-diagnosis-and-evaluation-of-glomerular-disease
bull Inker L Perrone R D Sterns R H amp Forman J P (2017 March 7) Assessment of kidney function Retrieved from UpToDate httpswww-uptodate-comproxywichitaeducontentsassessment-of-kidney-functionsource=search_resultampsearch=creatinineampselectedTitle=1~150
BIBLIOGRAPHY
bull James P A Ortiz E amp Et Al (2014) Evidence based guideline for the management of high blood pressure in adults (JNC) JAMA 311(5) 507-520
bull Kidney Disease Improving Global Outcomes (KDIGO) CKD Work Group (2013 January) KDIGO 2012 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease Retrieved from Kidney International Supplement httpwwwkidney-internationalorg
bull Kunz R Friedrich C Wolbers M amp Mann J F (2008) Meta-analysis effect of monotherapy and combination therapy with inhibitors of the renin angiotensin system on proteinuria in renal disease Annals of Internal Medicine 148(1) 30-48
bull Levey A Stevens L A Schmid C H Castro A F Feldman H I Kusek J W Coresh J (2009) A new equation to estimate glomerular filtration rate Annals of Internal Medicine 150(9) 604-612
bull Levin A Bakris G L Molitch M Smulders M M Williams L A amp Andress D L (2007 Jan) Prevalence of abnormal serum vitamin D PTH calcium and phosphorus in patients with chronic kidney disease results of the study to evaluate early kidney disease Kidney International 71(1) 31-38 Retrieved from PubMED
bull Mahajan A Simoni J Sheather S Broglio K Rajab M amp Wesson D (2010) Daily oral sodium bicarbonate preserves glomerular filtration rate by slowing its decline in early hypertensive nephropathy Kidney International (78_ 303-309
bull Mann J Schmieder R E amp McQueen M (2008) Renal outcomes with telmisartan ramipril or both in people at high vascular risk (the ONTARGET study) a multicentre randomised doubleblind ocntrolled trial Lancet 372(9638) 547-533
BIBLIOGRAPHY
bull Matovinović M S (2009) Pathophysiology and classification of kidney disease Retrieved from The Journal of the International Federation of Clinical Chemistry and Laboratory Medicine httpwwwifccorgifccfilesdocs20010902pdf
bull Moe S Drueke T Lameire N amp Eknoyan G (2007 Jan) Chronic kidney disease-mineral-bone disorder a new paradigmdoi101053jackd200610005
bull Murtagh F E Marsh J E Donohoe P Ekbal N J Sheerin N S amp Harris F E (2007 July) Dialysis or not A comparative survival study of patients over 75 years with chronic kidney disease stage 5 Retrieved from Nephrology Dialysis and Transplant 22(7) httpswwwncbinlmnihgovpubmed17412702
bull National Kidney Foundation (2002) KDOQI clinical practice guidelines for chronic kidney disease evaluation classification andstratification American Journal of Kidney Disease S1-S266
bull National Kidney Foundation (2014 November 5) Fact Sheets Retrieved from httpwwwkidneyorgnewsnewsroomfactsheetsFastFacts
bull Pal S (2012 June 2) Trends in chronic kidney disease Retrieved from US Pharmacist (37)6 httpswwwuspharmacistcomarticletrends-in-chronic-kidney-disease
bull Qunibi W amp Henrich W L (2017 Jan 19) Overview of chronic kidney disease-mineral and bone disorder (J Berns amp A M Sheridan Eds) Retrieved from UpToDate httpswww-uptodate-comoverview-of-chronic-kidney-disease-mineral-and-bone-disorder-ckd-mbd
bull Rosenberg M (2016 Feb 24) Overview of the management of chronic kidney disease in adults (G C Curhan amp A M Sheridan Eds) Retrieved from UpToDate UpToDate httpswww-uptodate-comproxywichitaeducontentsoverview-of-the-management-of-chronic-kidney-disease-in-adults
BIBLIOGRAPHY
bull Szczech L Stewart R C Hsu-Lin S DeLosky R J Astor B C Fox C H Vassalotti J A (2014) Primary care detection of chronic kidney disease in adults with type 2 diabetes The ADD-CKD Study (Awareness Detection and Drug Therapy in type 2 diabetes and chronic kidney disease PLOS doihttpsdoiorg101371journalpone0110535
bull USRDS (2016) Annual data report 2016 Epidemiology of kidney disease in the United States Retrieved from United States Renal Data System httpswwwusrdsorgadraspx
bull Vasudev B amp Vasudev M (2012) A model curriculum for residents rotating in nephrology MedEDPORTAL doihttpdoiorg1015766mep_2374-82658288
bull Wei L MacDonald T M Jennings C Sheng X amp Flynn R W (2013) Estimated GFR reporting is associated with decreased nonsteroidal anti-inflammatory drug prescribing and increased renal function Kidney International (84)1 174-178
chronic kidney disease in primary care
CKD as a Public Health Issue
Slide Number 3
Costs of CKD in 2013 dollarsUSRDS report
Steps to CKD Patient Care
Renal anatomy and physiology
Definition of Chronic Kidney Disease
CKD Risk Factors
Gaps in CKD Diagnosis
Slide Number 10
Steps to CKD Patient Care
creatinine
Glomerular filtration rate
Slide Number 14
Slide Number 15
Use These Equations Cautiously if at all in hellip
lab albumin creatinine ratio
The New CKD Categories
Steps to CKD Patient Care
Slide Number 20
Kidney Involvement in Systemic Diseases
Slide Number 22
Slide Number 23
DysmorphicRenal Hematuria
Slide Number 25
If you have albuminuria or hematuria-order the following labs
Prevalence of Abnormalities of Mineral Metabolism PTH in CKD
Managing CKD-MBD complications
CKD-MBD Testing
Anemia Becomes More Common as Kidney Function Declines
Detect and Manage CKD Complications
Complications-metabolic acidosis
Complications-vascular calcification
Hyperkalemia management
Hyperuricemia levels amp CKD
CKD monitoring levels 345
Slide Number 59
When to Refer to a Nephrologist
When to Refer
Steps to CKD Patient Care
Kidney transplantation
Starting Dialysis in the ElderlyhellipOr Not
Ckd management
Case 1
Slide Number 67
Lab results
Slide Number 69
Hypertensive nephropathy with proteinuria
Slide Number 71
Case 2
Slide Number 73
Management of CKD in Diabetes
Case 3
Case 3
Systemic Lupus Erythematosus (SLE)
SLE ndash Lupus Nephritis
Case 5
Case 5
Slide Number 81
Slide Number 82
Case study
Slide Number 84
CXR ndash Hilar Lymphadenopathy
Whats needed next
Slide Number 87
newly dx ckd
Slide Number 89
Bibliography
bibliography
bibliography
bibliography
bibliography
KIDNEY TRANSPLANTATION
bull Treatment of choice for ESRDbull Improves quality of lifebull Waiting list time varies-3-5 yearsbull 3 year survival rate after transplantation is 83-94bull Increased risk of cancer
STARTING DIALYSIS IN THE ELDERLYhellipOR NOT
bull Among patients gt 75 yrs with stage 5 CKD who chose to NOT start dialysisbull Overall more likely to die over next 1-2 years bull But if they had ischemic heart disease or other significant comorbidity NO
DIFFERENCE in survival
bull Active disease management and supportive care may be appropriate without starting dialysis in the ill elderly
bull Palliative care does not mean ldquono carerdquo
bull Must have end-of-life discussions
(Murtagh et al 2007)
CKD MANAGEMENTbull Diagnose cause and treat underlying conditionbull Stage per guidelinesbull Slow progression of kidney disease (ACE inhibitors)bull Monitor for complicationsmdashvolume overload hyperkalemia metabolic acidosis
hyperphosphatemia anorexia fatigue htn bone diseasebull Labs cmp cbc phos Vit D 25OH iPTH urine microscopy uric acid urine
proteincr ratio-frequency based off heat map Get sono at least oncebull Vaccinate influenza hep B pneumococcalbull Eval ASCVD risk-likely needs statinbull Possible dexa (donrsquot give bisphosphonates if GFRlt35 let specialist manage)bull Refer to nephrology when eGFR is lt30 (sometimes if higher risk-refer earlier)
CASE 1
bull 55 year old man with past medical history of headaches presents to your office for his first time visit to a PCP in over 30 years
bull He has no past history of being admitted to the hospital and he does not take any OTC medsNSAIDsherbal meds He has no history of ETOH abuse smoking or drug use
bull Vitals BP 180100 mmHg pulse 80 R 18
bull Exam No JVD S1S2 regular PMI shifted to the left no gallop no abdominal bruit pulses bilaterally equal and regular no leg edema
bull What would you order
bull EKG cbc cmp ua urine proteincr ratio lipid
LAB RESULTS
bull Labs reveal a creatinine of 22 mgdL eGFR 33 Urine shows no blood or casts Urineprotein ratio shows 1 gm protein24 hrs EKG shows LVH
bull Next step in workupbull Renal ultrasound 1st then SPEP UPEP with immunofixation serum free light chains
bull Additional labs neg Renal ultrasound shows that both kidneys are slightly reduced in size and are mildly echogenic with no mass or hydronephrosis
bull What is your diagnosis
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileMain_complications_of_persistent_high_blood_pressurepngCreative Commons License associated httpcreativecommonsorglicensesby-sa30
bull 3 months Howevermdashwe have evidence of structural abnormalities Could potentially stage at G3b A3 (red on the heat map)
bull Goal blood pressure
bull JNC 8 14090 NKF 13080
bull Additional lab needed for progression monitoring
bull Cbc renal panel phos Vit D iPTH uric acid urine micro (we already have the renal sono and urine proteincr ratio and lipid)
Selective renal angiography (left lower renal artery) after successful percutaneous balloon dilatation of the stenotic lesionFibromuscular dysplasia in an accessory renal artery causing renovascular hypertension
Secondary Hypertension
Images retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileRenal_FMD2jpg and httpcommonswikimediaorgwikiFileRenal_FMDjpgCreative Commons License associated httpcreativecommonsorglicensesby20deeden (both images)
CASE 2bull OS is a 64year old Hispanic female in for DM check She has had DM for 15+ years and is currently
taking metformin 1000mg bid Lisinopril 10mg a day atorvastatin 40mg a day Labs today showed the following
bull Hgba1c 86 cmp eGFR 50 lipid WNL proteincr ratio 650mg These results are similar to her last visit
bull Upon further hx-you find that she had a recent eye exam and has mild nonproliferaive retinopathy She does not have neuropathy or other ss
bull What further workup do you need
bull Renal sonogram urine micro iPTH vit D (25 OH) phos uric acid
bull Dx stage
bull G3a A3
bull What further treatment do you need
bull Improve glycemic control Increase Lisinopril to 20mg with a goal of 40mg Avoid NSAIDs or other nephrotoxic agents make sure meds are renally dosed monitor 3xyear nephro referral
MANAGEMENT OF CKD IN DIABETESeGFR Recommended
All patients
Yearly measurement of creatinine urinary albumin excretion potassium
45-60 Referral to a nephrologist if possibility for nondiabetickidney disease existsConsider dose adjustment of medicationsMonitor eGFR every 6 monthsMonitor electrolytes bicarbonate hemoglobin calcium phosphorus parathyroid hormone at least yearly
Assure vitamin D sufficiencyConsider bone density testingReferral for dietary counselling
American Diabetes Association Standards of Medical Care in Diabetes Microvascular complications and foot care Diabetes Care 2017 40 (Suppl 1) S88-S98
CASE 3
bull 19 year old African American woman presents to your clinic with complaints of fatigue joint pains a new rash on her face oral ulcer
bull On exam BP 15080 P 88 Afebrile 96 O2 sats on RAbull GEN No respiratory distress at restbull HEENT painless oral ulcer flat rash over malar eminences sparing the nasolabial fold pallor +bull Lungs CTAbull CVS S1S2 regularbull Abdomen soft NTbull Ext left elbow joint and bilateral wrist joints are swollen and tender
bull What would you orderbull CBC CMP ua urine microscopy (microalbumin or urine proteincr ratio) ANA esr RF anti-ccp uric acid TSH
CASE 3
bull Working dx fatigue oral ulcer joint pain
bull Basic Labs Na 135 K 55 Bicarb 18 BUN 50 Cr 35 eGFR 22 Ca 90 ANA + titer 1640
bull UA 3+ blood 3+ protein RBC casts +
bull Given these results what is the most likely diagnosis
bull What would you do
SYSTEMIC LUPUS ERYTHEMATOSUS (SLE)
bull SLE multisystemic disease Etiology unknown
bull Production of autoantibodies and immune complexes formation
bull There is renal involvement in the great majority of patients with SLE at some time of the evolution 66-90
SLE ndash LUPUS NEPHRITIS
bull Race SLE is more commonsevere in African americans than Caucasiansbull
bull Gender female-to-male ratio of 91
bull Age Most patients develop lupus nephritis early in their disease course SLE is more common among women in the third decade of life and lupus nephritis occurs in patients aged 20-40 years
bull Kidney Biopsy For staging lupus nephritis (Class 1-5)
CASE 5bull A 80 year old man who has not seen a PCP in many years
presents to your clinic for weakness for the past few months On further questioning he tells you that his bones also have been hurting lately and he has developed leg swelling in the past month or so
bull On exam bull BP 16090 P 88 Afebrilebull GEN Thin built manbull HEENT pallor presentbull Lungs clearbull CVS S1S2 regular no rub or gallopbull Abdomen soft NTbull Ext 2 + edema
CASE 5
bull Differentials
bull CHF MI Cancer arthritis
bull Labs
bull CBC CMP urine microscopy urine proteincr ratio ESR TSH EKG BNP pa and lat CXR
bull LABS Urine dipstick negative for protein or blood
bull Basic chem bull Na 136 (135-145) K 51 (35-55) Chloride 108 (96-106) Bicarb 25
Given this presentation and the labs (low anion gap and elevated calcium anemia kidney failure) what will you think of What will you order next
Serum and urine protein electrophoresis
Intratubular refractile casts with surrounding syncytial giant cell reaction with chronic tubulointerstitial nephritis and fibrosis characteristic of myeloma cast nephropathy
Kidney Biopsy
CASE STUDYbull A 35 year old African American woman was seen in the clinic for
chronic cough and dyspnea on exertion She gave history of vague symptoms of fatigue and weight loss of 20 Ibs over the last six months
bull List some differentialsbull TB sarcoid lupus thyroid problems PEbull What would you orderbull PPD cbc cmp UA TSH ANA pa and lat cxr
bull Her labs were significant for mildly elevated calcium level and a creatinine of 20 mgdL eGFR 37
bull She had 750 mg of proteinuriaday
bull PPD neg ANA neg TSH and other labs WNL
bull Assuming this is present more than 3 monthshelliphellipwhat is her ckd stage
bull G3b A3
bull What do we still need
CT scan of chest
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileAnterior_mediastinal_mass_thymomajpgCreative Commons License associated httpcreativecommonsorglicensesby20deeden
CXR ndash HILAR LYMPHADENOPATHY
WHATS NEEDED NEXT
bull Biopsy of hilar lymphadenopathy or renal biopsy
bull DX sarcoidosis
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileSarcoidosis_signs_and_symptomsjpgThis work is in the public domain in the United States because it is a work of the United States Federal Government under the terms of Title 17 Chapter 1 Section 105 of the US Code
NEWLY DX CKD
bull 1) urinalysis microscopy ultrasound proteincr ratio
bull If obstruction-treat
bull No obstruction
bull Hx critical (consider myeloma if high risk)
bull glomerular bleeding or albumin in urine
bull Yes workup for glomerular causes (ANArf hep B C upep spep ANCA complement C3 C4)
bull No sterile pyruria-consider interstitial nephritis
bull High risk renovascular disease Evaluate renovascular disease
Additional Online Resources for CKD LearningbullNational Kidney Foundation wwwkidneyorgbullUnited States Renal Data Service wwwusrdsorgbullCDCrsquos CKD Surveillance Project
httpnccdcdcgovckdbullNational Kidney Disease Education Program
(NKDEP) httpnkdepnihgov
BIBLIOGRAPHY
bull Afzali B amp Goldsmith D J (2016 June 29) Statins and chronic kidney disease (G C Curhan amp A M Sheridan Eds) Retrieved 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsstatins-and-chronic-kidney-disease
bull American Diabetes Association Standards of Medical Care in Diabetes (2017) Microvascular complications and foot care Diabetes Care 2017 (40) S88-S98
bull American Diabetes Association Standards of Medical Care in Diabetes (2017) Microvascular complications and foot care Diabetes Care 40 (suppl 1) S88-S98
bull Berns J S (2017 Mar 22) Treatment of anemia in nondialysis chronic kidney disease (T A Golper amp A M Sheridan Eds) Retrieved from UpToDate httpswww-uptodate-comproxywichitaeducontentstreatment-of-anemia-in-nondialysis-chronic-kidney-disease
bull Chan M Dall A T Fletcher K E Lu N amp Trivedi H (2007) Outcomes in patients with chronic kidney disease referred late to nephrologists a meta-analysis American Journal of Medicine 120(12) 1063-1070
bull Coresh J Selvin E amp Stevens L A (2007) Prevalence of chronic kidny disease in the United States JAMA 298(17) doi101001jama298172038
bull de Brito-Ashurst I Varagunam M Raftery M amp Yagoob M (2009) Bicarbonate supplementation slows progression of CKD and improves nutritional status Journal of American Society of Nephrology (20) 2075-2084
BIBLIOGRAPHY
bull Duncan L Heathcoat J Djurdjev O amp Levin A (2001) Screening for renal disease using serum creatinine who are we missing Nephrology Dialysis and Transplant 16(5) 1042-1046
bull Dunkler D Gao P Lee S F Heinz G Clase C M Tobe S Oberbauer R (2015 August 7) Risk prediction for early CKD in type 2 diabetes Retrieved from Clinical Journal of the American Society of Nephrology httpcjasnasnjournalsorgcontent1081371fullsid=61422554-a5f1-41ac-b696-dcd3b12bd268
bull Fatehi P amp Chi-yuan H (September 15 2016) Diagnostic approach to the patient with newly identified chronic kidney disease (G C Curhan amp A M Sheridan Eds) Retrieved May 7 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsdiagnostic-approach-to-the-patient-with-newly-identified-chronic-kidney-disease
bull Fink J e (2009) Chronic Kidney Disease as an Under-Recognized Threat to Patient Safety American journal of kidney diseases the official journal of the National Kidney Foundation 53(4) 681-688
bull Gaffo A L amp Saag K G (2008 Nov) Management of hyperuricemia and gout in CKD doihttpdxdoiorg101053jajkd200807035
bull Hebert L A amp Parikh S V (2014 June 18) Differential diagnosis and evaluation of glomerular disease (R J Glassock amp A Q Lam Eds) Retrieved May 7 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsdifferential-diagnosis-and-evaluation-of-glomerular-disease
bull Inker L Perrone R D Sterns R H amp Forman J P (2017 March 7) Assessment of kidney function Retrieved from UpToDate httpswww-uptodate-comproxywichitaeducontentsassessment-of-kidney-functionsource=search_resultampsearch=creatinineampselectedTitle=1~150
BIBLIOGRAPHY
bull James P A Ortiz E amp Et Al (2014) Evidence based guideline for the management of high blood pressure in adults (JNC) JAMA 311(5) 507-520
bull Kidney Disease Improving Global Outcomes (KDIGO) CKD Work Group (2013 January) KDIGO 2012 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease Retrieved from Kidney International Supplement httpwwwkidney-internationalorg
bull Kunz R Friedrich C Wolbers M amp Mann J F (2008) Meta-analysis effect of monotherapy and combination therapy with inhibitors of the renin angiotensin system on proteinuria in renal disease Annals of Internal Medicine 148(1) 30-48
bull Levey A Stevens L A Schmid C H Castro A F Feldman H I Kusek J W Coresh J (2009) A new equation to estimate glomerular filtration rate Annals of Internal Medicine 150(9) 604-612
bull Levin A Bakris G L Molitch M Smulders M M Williams L A amp Andress D L (2007 Jan) Prevalence of abnormal serum vitamin D PTH calcium and phosphorus in patients with chronic kidney disease results of the study to evaluate early kidney disease Kidney International 71(1) 31-38 Retrieved from PubMED
bull Mahajan A Simoni J Sheather S Broglio K Rajab M amp Wesson D (2010) Daily oral sodium bicarbonate preserves glomerular filtration rate by slowing its decline in early hypertensive nephropathy Kidney International (78_ 303-309
bull Mann J Schmieder R E amp McQueen M (2008) Renal outcomes with telmisartan ramipril or both in people at high vascular risk (the ONTARGET study) a multicentre randomised doubleblind ocntrolled trial Lancet 372(9638) 547-533
BIBLIOGRAPHY
bull Matovinović M S (2009) Pathophysiology and classification of kidney disease Retrieved from The Journal of the International Federation of Clinical Chemistry and Laboratory Medicine httpwwwifccorgifccfilesdocs20010902pdf
bull Moe S Drueke T Lameire N amp Eknoyan G (2007 Jan) Chronic kidney disease-mineral-bone disorder a new paradigmdoi101053jackd200610005
bull Murtagh F E Marsh J E Donohoe P Ekbal N J Sheerin N S amp Harris F E (2007 July) Dialysis or not A comparative survival study of patients over 75 years with chronic kidney disease stage 5 Retrieved from Nephrology Dialysis and Transplant 22(7) httpswwwncbinlmnihgovpubmed17412702
bull National Kidney Foundation (2002) KDOQI clinical practice guidelines for chronic kidney disease evaluation classification andstratification American Journal of Kidney Disease S1-S266
bull National Kidney Foundation (2014 November 5) Fact Sheets Retrieved from httpwwwkidneyorgnewsnewsroomfactsheetsFastFacts
bull Pal S (2012 June 2) Trends in chronic kidney disease Retrieved from US Pharmacist (37)6 httpswwwuspharmacistcomarticletrends-in-chronic-kidney-disease
bull Qunibi W amp Henrich W L (2017 Jan 19) Overview of chronic kidney disease-mineral and bone disorder (J Berns amp A M Sheridan Eds) Retrieved from UpToDate httpswww-uptodate-comoverview-of-chronic-kidney-disease-mineral-and-bone-disorder-ckd-mbd
bull Rosenberg M (2016 Feb 24) Overview of the management of chronic kidney disease in adults (G C Curhan amp A M Sheridan Eds) Retrieved from UpToDate UpToDate httpswww-uptodate-comproxywichitaeducontentsoverview-of-the-management-of-chronic-kidney-disease-in-adults
BIBLIOGRAPHY
bull Szczech L Stewart R C Hsu-Lin S DeLosky R J Astor B C Fox C H Vassalotti J A (2014) Primary care detection of chronic kidney disease in adults with type 2 diabetes The ADD-CKD Study (Awareness Detection and Drug Therapy in type 2 diabetes and chronic kidney disease PLOS doihttpsdoiorg101371journalpone0110535
bull USRDS (2016) Annual data report 2016 Epidemiology of kidney disease in the United States Retrieved from United States Renal Data System httpswwwusrdsorgadraspx
bull Vasudev B amp Vasudev M (2012) A model curriculum for residents rotating in nephrology MedEDPORTAL doihttpdoiorg1015766mep_2374-82658288
bull Wei L MacDonald T M Jennings C Sheng X amp Flynn R W (2013) Estimated GFR reporting is associated with decreased nonsteroidal anti-inflammatory drug prescribing and increased renal function Kidney International (84)1 174-178
chronic kidney disease in primary care
CKD as a Public Health Issue
Slide Number 3
Costs of CKD in 2013 dollarsUSRDS report
Steps to CKD Patient Care
Renal anatomy and physiology
Definition of Chronic Kidney Disease
CKD Risk Factors
Gaps in CKD Diagnosis
Slide Number 10
Steps to CKD Patient Care
creatinine
Glomerular filtration rate
Slide Number 14
Slide Number 15
Use These Equations Cautiously if at all in hellip
lab albumin creatinine ratio
The New CKD Categories
Steps to CKD Patient Care
Slide Number 20
Kidney Involvement in Systemic Diseases
Slide Number 22
Slide Number 23
DysmorphicRenal Hematuria
Slide Number 25
If you have albuminuria or hematuria-order the following labs
Prevalence of Abnormalities of Mineral Metabolism PTH in CKD
Managing CKD-MBD complications
CKD-MBD Testing
Anemia Becomes More Common as Kidney Function Declines
Detect and Manage CKD Complications
Complications-metabolic acidosis
Complications-vascular calcification
Hyperkalemia management
Hyperuricemia levels amp CKD
CKD monitoring levels 345
Slide Number 59
When to Refer to a Nephrologist
When to Refer
Steps to CKD Patient Care
Kidney transplantation
Starting Dialysis in the ElderlyhellipOr Not
Ckd management
Case 1
Slide Number 67
Lab results
Slide Number 69
Hypertensive nephropathy with proteinuria
Slide Number 71
Case 2
Slide Number 73
Management of CKD in Diabetes
Case 3
Case 3
Systemic Lupus Erythematosus (SLE)
SLE ndash Lupus Nephritis
Case 5
Case 5
Slide Number 81
Slide Number 82
Case study
Slide Number 84
CXR ndash Hilar Lymphadenopathy
Whats needed next
Slide Number 87
newly dx ckd
Slide Number 89
Bibliography
bibliography
bibliography
bibliography
bibliography
STARTING DIALYSIS IN THE ELDERLYhellipOR NOT
bull Among patients gt 75 yrs with stage 5 CKD who chose to NOT start dialysisbull Overall more likely to die over next 1-2 years bull But if they had ischemic heart disease or other significant comorbidity NO
DIFFERENCE in survival
bull Active disease management and supportive care may be appropriate without starting dialysis in the ill elderly
bull Palliative care does not mean ldquono carerdquo
bull Must have end-of-life discussions
(Murtagh et al 2007)
CKD MANAGEMENTbull Diagnose cause and treat underlying conditionbull Stage per guidelinesbull Slow progression of kidney disease (ACE inhibitors)bull Monitor for complicationsmdashvolume overload hyperkalemia metabolic acidosis
hyperphosphatemia anorexia fatigue htn bone diseasebull Labs cmp cbc phos Vit D 25OH iPTH urine microscopy uric acid urine
proteincr ratio-frequency based off heat map Get sono at least oncebull Vaccinate influenza hep B pneumococcalbull Eval ASCVD risk-likely needs statinbull Possible dexa (donrsquot give bisphosphonates if GFRlt35 let specialist manage)bull Refer to nephrology when eGFR is lt30 (sometimes if higher risk-refer earlier)
CASE 1
bull 55 year old man with past medical history of headaches presents to your office for his first time visit to a PCP in over 30 years
bull He has no past history of being admitted to the hospital and he does not take any OTC medsNSAIDsherbal meds He has no history of ETOH abuse smoking or drug use
bull Vitals BP 180100 mmHg pulse 80 R 18
bull Exam No JVD S1S2 regular PMI shifted to the left no gallop no abdominal bruit pulses bilaterally equal and regular no leg edema
bull What would you order
bull EKG cbc cmp ua urine proteincr ratio lipid
LAB RESULTS
bull Labs reveal a creatinine of 22 mgdL eGFR 33 Urine shows no blood or casts Urineprotein ratio shows 1 gm protein24 hrs EKG shows LVH
bull Next step in workupbull Renal ultrasound 1st then SPEP UPEP with immunofixation serum free light chains
bull Additional labs neg Renal ultrasound shows that both kidneys are slightly reduced in size and are mildly echogenic with no mass or hydronephrosis
bull What is your diagnosis
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileMain_complications_of_persistent_high_blood_pressurepngCreative Commons License associated httpcreativecommonsorglicensesby-sa30
bull 3 months Howevermdashwe have evidence of structural abnormalities Could potentially stage at G3b A3 (red on the heat map)
bull Goal blood pressure
bull JNC 8 14090 NKF 13080
bull Additional lab needed for progression monitoring
bull Cbc renal panel phos Vit D iPTH uric acid urine micro (we already have the renal sono and urine proteincr ratio and lipid)
Selective renal angiography (left lower renal artery) after successful percutaneous balloon dilatation of the stenotic lesionFibromuscular dysplasia in an accessory renal artery causing renovascular hypertension
Secondary Hypertension
Images retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileRenal_FMD2jpg and httpcommonswikimediaorgwikiFileRenal_FMDjpgCreative Commons License associated httpcreativecommonsorglicensesby20deeden (both images)
CASE 2bull OS is a 64year old Hispanic female in for DM check She has had DM for 15+ years and is currently
taking metformin 1000mg bid Lisinopril 10mg a day atorvastatin 40mg a day Labs today showed the following
bull Hgba1c 86 cmp eGFR 50 lipid WNL proteincr ratio 650mg These results are similar to her last visit
bull Upon further hx-you find that she had a recent eye exam and has mild nonproliferaive retinopathy She does not have neuropathy or other ss
bull What further workup do you need
bull Renal sonogram urine micro iPTH vit D (25 OH) phos uric acid
bull Dx stage
bull G3a A3
bull What further treatment do you need
bull Improve glycemic control Increase Lisinopril to 20mg with a goal of 40mg Avoid NSAIDs or other nephrotoxic agents make sure meds are renally dosed monitor 3xyear nephro referral
MANAGEMENT OF CKD IN DIABETESeGFR Recommended
All patients
Yearly measurement of creatinine urinary albumin excretion potassium
45-60 Referral to a nephrologist if possibility for nondiabetickidney disease existsConsider dose adjustment of medicationsMonitor eGFR every 6 monthsMonitor electrolytes bicarbonate hemoglobin calcium phosphorus parathyroid hormone at least yearly
Assure vitamin D sufficiencyConsider bone density testingReferral for dietary counselling
American Diabetes Association Standards of Medical Care in Diabetes Microvascular complications and foot care Diabetes Care 2017 40 (Suppl 1) S88-S98
CASE 3
bull 19 year old African American woman presents to your clinic with complaints of fatigue joint pains a new rash on her face oral ulcer
bull On exam BP 15080 P 88 Afebrile 96 O2 sats on RAbull GEN No respiratory distress at restbull HEENT painless oral ulcer flat rash over malar eminences sparing the nasolabial fold pallor +bull Lungs CTAbull CVS S1S2 regularbull Abdomen soft NTbull Ext left elbow joint and bilateral wrist joints are swollen and tender
bull What would you orderbull CBC CMP ua urine microscopy (microalbumin or urine proteincr ratio) ANA esr RF anti-ccp uric acid TSH
CASE 3
bull Working dx fatigue oral ulcer joint pain
bull Basic Labs Na 135 K 55 Bicarb 18 BUN 50 Cr 35 eGFR 22 Ca 90 ANA + titer 1640
bull UA 3+ blood 3+ protein RBC casts +
bull Given these results what is the most likely diagnosis
bull What would you do
SYSTEMIC LUPUS ERYTHEMATOSUS (SLE)
bull SLE multisystemic disease Etiology unknown
bull Production of autoantibodies and immune complexes formation
bull There is renal involvement in the great majority of patients with SLE at some time of the evolution 66-90
SLE ndash LUPUS NEPHRITIS
bull Race SLE is more commonsevere in African americans than Caucasiansbull
bull Gender female-to-male ratio of 91
bull Age Most patients develop lupus nephritis early in their disease course SLE is more common among women in the third decade of life and lupus nephritis occurs in patients aged 20-40 years
bull Kidney Biopsy For staging lupus nephritis (Class 1-5)
CASE 5bull A 80 year old man who has not seen a PCP in many years
presents to your clinic for weakness for the past few months On further questioning he tells you that his bones also have been hurting lately and he has developed leg swelling in the past month or so
bull On exam bull BP 16090 P 88 Afebrilebull GEN Thin built manbull HEENT pallor presentbull Lungs clearbull CVS S1S2 regular no rub or gallopbull Abdomen soft NTbull Ext 2 + edema
CASE 5
bull Differentials
bull CHF MI Cancer arthritis
bull Labs
bull CBC CMP urine microscopy urine proteincr ratio ESR TSH EKG BNP pa and lat CXR
bull LABS Urine dipstick negative for protein or blood
bull Basic chem bull Na 136 (135-145) K 51 (35-55) Chloride 108 (96-106) Bicarb 25
Given this presentation and the labs (low anion gap and elevated calcium anemia kidney failure) what will you think of What will you order next
Serum and urine protein electrophoresis
Intratubular refractile casts with surrounding syncytial giant cell reaction with chronic tubulointerstitial nephritis and fibrosis characteristic of myeloma cast nephropathy
Kidney Biopsy
CASE STUDYbull A 35 year old African American woman was seen in the clinic for
chronic cough and dyspnea on exertion She gave history of vague symptoms of fatigue and weight loss of 20 Ibs over the last six months
bull List some differentialsbull TB sarcoid lupus thyroid problems PEbull What would you orderbull PPD cbc cmp UA TSH ANA pa and lat cxr
bull Her labs were significant for mildly elevated calcium level and a creatinine of 20 mgdL eGFR 37
bull She had 750 mg of proteinuriaday
bull PPD neg ANA neg TSH and other labs WNL
bull Assuming this is present more than 3 monthshelliphellipwhat is her ckd stage
bull G3b A3
bull What do we still need
CT scan of chest
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileAnterior_mediastinal_mass_thymomajpgCreative Commons License associated httpcreativecommonsorglicensesby20deeden
CXR ndash HILAR LYMPHADENOPATHY
WHATS NEEDED NEXT
bull Biopsy of hilar lymphadenopathy or renal biopsy
bull DX sarcoidosis
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileSarcoidosis_signs_and_symptomsjpgThis work is in the public domain in the United States because it is a work of the United States Federal Government under the terms of Title 17 Chapter 1 Section 105 of the US Code
NEWLY DX CKD
bull 1) urinalysis microscopy ultrasound proteincr ratio
bull If obstruction-treat
bull No obstruction
bull Hx critical (consider myeloma if high risk)
bull glomerular bleeding or albumin in urine
bull Yes workup for glomerular causes (ANArf hep B C upep spep ANCA complement C3 C4)
bull No sterile pyruria-consider interstitial nephritis
bull High risk renovascular disease Evaluate renovascular disease
Additional Online Resources for CKD LearningbullNational Kidney Foundation wwwkidneyorgbullUnited States Renal Data Service wwwusrdsorgbullCDCrsquos CKD Surveillance Project
httpnccdcdcgovckdbullNational Kidney Disease Education Program
(NKDEP) httpnkdepnihgov
BIBLIOGRAPHY
bull Afzali B amp Goldsmith D J (2016 June 29) Statins and chronic kidney disease (G C Curhan amp A M Sheridan Eds) Retrieved 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsstatins-and-chronic-kidney-disease
bull American Diabetes Association Standards of Medical Care in Diabetes (2017) Microvascular complications and foot care Diabetes Care 2017 (40) S88-S98
bull American Diabetes Association Standards of Medical Care in Diabetes (2017) Microvascular complications and foot care Diabetes Care 40 (suppl 1) S88-S98
bull Berns J S (2017 Mar 22) Treatment of anemia in nondialysis chronic kidney disease (T A Golper amp A M Sheridan Eds) Retrieved from UpToDate httpswww-uptodate-comproxywichitaeducontentstreatment-of-anemia-in-nondialysis-chronic-kidney-disease
bull Chan M Dall A T Fletcher K E Lu N amp Trivedi H (2007) Outcomes in patients with chronic kidney disease referred late to nephrologists a meta-analysis American Journal of Medicine 120(12) 1063-1070
bull Coresh J Selvin E amp Stevens L A (2007) Prevalence of chronic kidny disease in the United States JAMA 298(17) doi101001jama298172038
bull de Brito-Ashurst I Varagunam M Raftery M amp Yagoob M (2009) Bicarbonate supplementation slows progression of CKD and improves nutritional status Journal of American Society of Nephrology (20) 2075-2084
BIBLIOGRAPHY
bull Duncan L Heathcoat J Djurdjev O amp Levin A (2001) Screening for renal disease using serum creatinine who are we missing Nephrology Dialysis and Transplant 16(5) 1042-1046
bull Dunkler D Gao P Lee S F Heinz G Clase C M Tobe S Oberbauer R (2015 August 7) Risk prediction for early CKD in type 2 diabetes Retrieved from Clinical Journal of the American Society of Nephrology httpcjasnasnjournalsorgcontent1081371fullsid=61422554-a5f1-41ac-b696-dcd3b12bd268
bull Fatehi P amp Chi-yuan H (September 15 2016) Diagnostic approach to the patient with newly identified chronic kidney disease (G C Curhan amp A M Sheridan Eds) Retrieved May 7 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsdiagnostic-approach-to-the-patient-with-newly-identified-chronic-kidney-disease
bull Fink J e (2009) Chronic Kidney Disease as an Under-Recognized Threat to Patient Safety American journal of kidney diseases the official journal of the National Kidney Foundation 53(4) 681-688
bull Gaffo A L amp Saag K G (2008 Nov) Management of hyperuricemia and gout in CKD doihttpdxdoiorg101053jajkd200807035
bull Hebert L A amp Parikh S V (2014 June 18) Differential diagnosis and evaluation of glomerular disease (R J Glassock amp A Q Lam Eds) Retrieved May 7 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsdifferential-diagnosis-and-evaluation-of-glomerular-disease
bull Inker L Perrone R D Sterns R H amp Forman J P (2017 March 7) Assessment of kidney function Retrieved from UpToDate httpswww-uptodate-comproxywichitaeducontentsassessment-of-kidney-functionsource=search_resultampsearch=creatinineampselectedTitle=1~150
BIBLIOGRAPHY
bull James P A Ortiz E amp Et Al (2014) Evidence based guideline for the management of high blood pressure in adults (JNC) JAMA 311(5) 507-520
bull Kidney Disease Improving Global Outcomes (KDIGO) CKD Work Group (2013 January) KDIGO 2012 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease Retrieved from Kidney International Supplement httpwwwkidney-internationalorg
bull Kunz R Friedrich C Wolbers M amp Mann J F (2008) Meta-analysis effect of monotherapy and combination therapy with inhibitors of the renin angiotensin system on proteinuria in renal disease Annals of Internal Medicine 148(1) 30-48
bull Levey A Stevens L A Schmid C H Castro A F Feldman H I Kusek J W Coresh J (2009) A new equation to estimate glomerular filtration rate Annals of Internal Medicine 150(9) 604-612
bull Levin A Bakris G L Molitch M Smulders M M Williams L A amp Andress D L (2007 Jan) Prevalence of abnormal serum vitamin D PTH calcium and phosphorus in patients with chronic kidney disease results of the study to evaluate early kidney disease Kidney International 71(1) 31-38 Retrieved from PubMED
bull Mahajan A Simoni J Sheather S Broglio K Rajab M amp Wesson D (2010) Daily oral sodium bicarbonate preserves glomerular filtration rate by slowing its decline in early hypertensive nephropathy Kidney International (78_ 303-309
bull Mann J Schmieder R E amp McQueen M (2008) Renal outcomes with telmisartan ramipril or both in people at high vascular risk (the ONTARGET study) a multicentre randomised doubleblind ocntrolled trial Lancet 372(9638) 547-533
BIBLIOGRAPHY
bull Matovinović M S (2009) Pathophysiology and classification of kidney disease Retrieved from The Journal of the International Federation of Clinical Chemistry and Laboratory Medicine httpwwwifccorgifccfilesdocs20010902pdf
bull Moe S Drueke T Lameire N amp Eknoyan G (2007 Jan) Chronic kidney disease-mineral-bone disorder a new paradigmdoi101053jackd200610005
bull Murtagh F E Marsh J E Donohoe P Ekbal N J Sheerin N S amp Harris F E (2007 July) Dialysis or not A comparative survival study of patients over 75 years with chronic kidney disease stage 5 Retrieved from Nephrology Dialysis and Transplant 22(7) httpswwwncbinlmnihgovpubmed17412702
bull National Kidney Foundation (2002) KDOQI clinical practice guidelines for chronic kidney disease evaluation classification andstratification American Journal of Kidney Disease S1-S266
bull National Kidney Foundation (2014 November 5) Fact Sheets Retrieved from httpwwwkidneyorgnewsnewsroomfactsheetsFastFacts
bull Pal S (2012 June 2) Trends in chronic kidney disease Retrieved from US Pharmacist (37)6 httpswwwuspharmacistcomarticletrends-in-chronic-kidney-disease
bull Qunibi W amp Henrich W L (2017 Jan 19) Overview of chronic kidney disease-mineral and bone disorder (J Berns amp A M Sheridan Eds) Retrieved from UpToDate httpswww-uptodate-comoverview-of-chronic-kidney-disease-mineral-and-bone-disorder-ckd-mbd
bull Rosenberg M (2016 Feb 24) Overview of the management of chronic kidney disease in adults (G C Curhan amp A M Sheridan Eds) Retrieved from UpToDate UpToDate httpswww-uptodate-comproxywichitaeducontentsoverview-of-the-management-of-chronic-kidney-disease-in-adults
BIBLIOGRAPHY
bull Szczech L Stewart R C Hsu-Lin S DeLosky R J Astor B C Fox C H Vassalotti J A (2014) Primary care detection of chronic kidney disease in adults with type 2 diabetes The ADD-CKD Study (Awareness Detection and Drug Therapy in type 2 diabetes and chronic kidney disease PLOS doihttpsdoiorg101371journalpone0110535
bull USRDS (2016) Annual data report 2016 Epidemiology of kidney disease in the United States Retrieved from United States Renal Data System httpswwwusrdsorgadraspx
bull Vasudev B amp Vasudev M (2012) A model curriculum for residents rotating in nephrology MedEDPORTAL doihttpdoiorg1015766mep_2374-82658288
bull Wei L MacDonald T M Jennings C Sheng X amp Flynn R W (2013) Estimated GFR reporting is associated with decreased nonsteroidal anti-inflammatory drug prescribing and increased renal function Kidney International (84)1 174-178
chronic kidney disease in primary care
CKD as a Public Health Issue
Slide Number 3
Costs of CKD in 2013 dollarsUSRDS report
Steps to CKD Patient Care
Renal anatomy and physiology
Definition of Chronic Kidney Disease
CKD Risk Factors
Gaps in CKD Diagnosis
Slide Number 10
Steps to CKD Patient Care
creatinine
Glomerular filtration rate
Slide Number 14
Slide Number 15
Use These Equations Cautiously if at all in hellip
lab albumin creatinine ratio
The New CKD Categories
Steps to CKD Patient Care
Slide Number 20
Kidney Involvement in Systemic Diseases
Slide Number 22
Slide Number 23
DysmorphicRenal Hematuria
Slide Number 25
If you have albuminuria or hematuria-order the following labs
Prevalence of Abnormalities of Mineral Metabolism PTH in CKD
Managing CKD-MBD complications
CKD-MBD Testing
Anemia Becomes More Common as Kidney Function Declines
Detect and Manage CKD Complications
Complications-metabolic acidosis
Complications-vascular calcification
Hyperkalemia management
Hyperuricemia levels amp CKD
CKD monitoring levels 345
Slide Number 59
When to Refer to a Nephrologist
When to Refer
Steps to CKD Patient Care
Kidney transplantation
Starting Dialysis in the ElderlyhellipOr Not
Ckd management
Case 1
Slide Number 67
Lab results
Slide Number 69
Hypertensive nephropathy with proteinuria
Slide Number 71
Case 2
Slide Number 73
Management of CKD in Diabetes
Case 3
Case 3
Systemic Lupus Erythematosus (SLE)
SLE ndash Lupus Nephritis
Case 5
Case 5
Slide Number 81
Slide Number 82
Case study
Slide Number 84
CXR ndash Hilar Lymphadenopathy
Whats needed next
Slide Number 87
newly dx ckd
Slide Number 89
Bibliography
bibliography
bibliography
bibliography
bibliography
CKD MANAGEMENTbull Diagnose cause and treat underlying conditionbull Stage per guidelinesbull Slow progression of kidney disease (ACE inhibitors)bull Monitor for complicationsmdashvolume overload hyperkalemia metabolic acidosis
hyperphosphatemia anorexia fatigue htn bone diseasebull Labs cmp cbc phos Vit D 25OH iPTH urine microscopy uric acid urine
proteincr ratio-frequency based off heat map Get sono at least oncebull Vaccinate influenza hep B pneumococcalbull Eval ASCVD risk-likely needs statinbull Possible dexa (donrsquot give bisphosphonates if GFRlt35 let specialist manage)bull Refer to nephrology when eGFR is lt30 (sometimes if higher risk-refer earlier)
CASE 1
bull 55 year old man with past medical history of headaches presents to your office for his first time visit to a PCP in over 30 years
bull He has no past history of being admitted to the hospital and he does not take any OTC medsNSAIDsherbal meds He has no history of ETOH abuse smoking or drug use
bull Vitals BP 180100 mmHg pulse 80 R 18
bull Exam No JVD S1S2 regular PMI shifted to the left no gallop no abdominal bruit pulses bilaterally equal and regular no leg edema
bull What would you order
bull EKG cbc cmp ua urine proteincr ratio lipid
LAB RESULTS
bull Labs reveal a creatinine of 22 mgdL eGFR 33 Urine shows no blood or casts Urineprotein ratio shows 1 gm protein24 hrs EKG shows LVH
bull Next step in workupbull Renal ultrasound 1st then SPEP UPEP with immunofixation serum free light chains
bull Additional labs neg Renal ultrasound shows that both kidneys are slightly reduced in size and are mildly echogenic with no mass or hydronephrosis
bull What is your diagnosis
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileMain_complications_of_persistent_high_blood_pressurepngCreative Commons License associated httpcreativecommonsorglicensesby-sa30
bull 3 months Howevermdashwe have evidence of structural abnormalities Could potentially stage at G3b A3 (red on the heat map)
bull Goal blood pressure
bull JNC 8 14090 NKF 13080
bull Additional lab needed for progression monitoring
bull Cbc renal panel phos Vit D iPTH uric acid urine micro (we already have the renal sono and urine proteincr ratio and lipid)
Selective renal angiography (left lower renal artery) after successful percutaneous balloon dilatation of the stenotic lesionFibromuscular dysplasia in an accessory renal artery causing renovascular hypertension
Secondary Hypertension
Images retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileRenal_FMD2jpg and httpcommonswikimediaorgwikiFileRenal_FMDjpgCreative Commons License associated httpcreativecommonsorglicensesby20deeden (both images)
CASE 2bull OS is a 64year old Hispanic female in for DM check She has had DM for 15+ years and is currently
taking metformin 1000mg bid Lisinopril 10mg a day atorvastatin 40mg a day Labs today showed the following
bull Hgba1c 86 cmp eGFR 50 lipid WNL proteincr ratio 650mg These results are similar to her last visit
bull Upon further hx-you find that she had a recent eye exam and has mild nonproliferaive retinopathy She does not have neuropathy or other ss
bull What further workup do you need
bull Renal sonogram urine micro iPTH vit D (25 OH) phos uric acid
bull Dx stage
bull G3a A3
bull What further treatment do you need
bull Improve glycemic control Increase Lisinopril to 20mg with a goal of 40mg Avoid NSAIDs or other nephrotoxic agents make sure meds are renally dosed monitor 3xyear nephro referral
MANAGEMENT OF CKD IN DIABETESeGFR Recommended
All patients
Yearly measurement of creatinine urinary albumin excretion potassium
45-60 Referral to a nephrologist if possibility for nondiabetickidney disease existsConsider dose adjustment of medicationsMonitor eGFR every 6 monthsMonitor electrolytes bicarbonate hemoglobin calcium phosphorus parathyroid hormone at least yearly
Assure vitamin D sufficiencyConsider bone density testingReferral for dietary counselling
American Diabetes Association Standards of Medical Care in Diabetes Microvascular complications and foot care Diabetes Care 2017 40 (Suppl 1) S88-S98
CASE 3
bull 19 year old African American woman presents to your clinic with complaints of fatigue joint pains a new rash on her face oral ulcer
bull On exam BP 15080 P 88 Afebrile 96 O2 sats on RAbull GEN No respiratory distress at restbull HEENT painless oral ulcer flat rash over malar eminences sparing the nasolabial fold pallor +bull Lungs CTAbull CVS S1S2 regularbull Abdomen soft NTbull Ext left elbow joint and bilateral wrist joints are swollen and tender
bull What would you orderbull CBC CMP ua urine microscopy (microalbumin or urine proteincr ratio) ANA esr RF anti-ccp uric acid TSH
CASE 3
bull Working dx fatigue oral ulcer joint pain
bull Basic Labs Na 135 K 55 Bicarb 18 BUN 50 Cr 35 eGFR 22 Ca 90 ANA + titer 1640
bull UA 3+ blood 3+ protein RBC casts +
bull Given these results what is the most likely diagnosis
bull What would you do
SYSTEMIC LUPUS ERYTHEMATOSUS (SLE)
bull SLE multisystemic disease Etiology unknown
bull Production of autoantibodies and immune complexes formation
bull There is renal involvement in the great majority of patients with SLE at some time of the evolution 66-90
SLE ndash LUPUS NEPHRITIS
bull Race SLE is more commonsevere in African americans than Caucasiansbull
bull Gender female-to-male ratio of 91
bull Age Most patients develop lupus nephritis early in their disease course SLE is more common among women in the third decade of life and lupus nephritis occurs in patients aged 20-40 years
bull Kidney Biopsy For staging lupus nephritis (Class 1-5)
CASE 5bull A 80 year old man who has not seen a PCP in many years
presents to your clinic for weakness for the past few months On further questioning he tells you that his bones also have been hurting lately and he has developed leg swelling in the past month or so
bull On exam bull BP 16090 P 88 Afebrilebull GEN Thin built manbull HEENT pallor presentbull Lungs clearbull CVS S1S2 regular no rub or gallopbull Abdomen soft NTbull Ext 2 + edema
CASE 5
bull Differentials
bull CHF MI Cancer arthritis
bull Labs
bull CBC CMP urine microscopy urine proteincr ratio ESR TSH EKG BNP pa and lat CXR
bull LABS Urine dipstick negative for protein or blood
bull Basic chem bull Na 136 (135-145) K 51 (35-55) Chloride 108 (96-106) Bicarb 25
Given this presentation and the labs (low anion gap and elevated calcium anemia kidney failure) what will you think of What will you order next
Serum and urine protein electrophoresis
Intratubular refractile casts with surrounding syncytial giant cell reaction with chronic tubulointerstitial nephritis and fibrosis characteristic of myeloma cast nephropathy
Kidney Biopsy
CASE STUDYbull A 35 year old African American woman was seen in the clinic for
chronic cough and dyspnea on exertion She gave history of vague symptoms of fatigue and weight loss of 20 Ibs over the last six months
bull List some differentialsbull TB sarcoid lupus thyroid problems PEbull What would you orderbull PPD cbc cmp UA TSH ANA pa and lat cxr
bull Her labs were significant for mildly elevated calcium level and a creatinine of 20 mgdL eGFR 37
bull She had 750 mg of proteinuriaday
bull PPD neg ANA neg TSH and other labs WNL
bull Assuming this is present more than 3 monthshelliphellipwhat is her ckd stage
bull G3b A3
bull What do we still need
CT scan of chest
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileAnterior_mediastinal_mass_thymomajpgCreative Commons License associated httpcreativecommonsorglicensesby20deeden
CXR ndash HILAR LYMPHADENOPATHY
WHATS NEEDED NEXT
bull Biopsy of hilar lymphadenopathy or renal biopsy
bull DX sarcoidosis
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileSarcoidosis_signs_and_symptomsjpgThis work is in the public domain in the United States because it is a work of the United States Federal Government under the terms of Title 17 Chapter 1 Section 105 of the US Code
NEWLY DX CKD
bull 1) urinalysis microscopy ultrasound proteincr ratio
bull If obstruction-treat
bull No obstruction
bull Hx critical (consider myeloma if high risk)
bull glomerular bleeding or albumin in urine
bull Yes workup for glomerular causes (ANArf hep B C upep spep ANCA complement C3 C4)
bull No sterile pyruria-consider interstitial nephritis
bull High risk renovascular disease Evaluate renovascular disease
Additional Online Resources for CKD LearningbullNational Kidney Foundation wwwkidneyorgbullUnited States Renal Data Service wwwusrdsorgbullCDCrsquos CKD Surveillance Project
httpnccdcdcgovckdbullNational Kidney Disease Education Program
(NKDEP) httpnkdepnihgov
BIBLIOGRAPHY
bull Afzali B amp Goldsmith D J (2016 June 29) Statins and chronic kidney disease (G C Curhan amp A M Sheridan Eds) Retrieved 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsstatins-and-chronic-kidney-disease
bull American Diabetes Association Standards of Medical Care in Diabetes (2017) Microvascular complications and foot care Diabetes Care 2017 (40) S88-S98
bull American Diabetes Association Standards of Medical Care in Diabetes (2017) Microvascular complications and foot care Diabetes Care 40 (suppl 1) S88-S98
bull Berns J S (2017 Mar 22) Treatment of anemia in nondialysis chronic kidney disease (T A Golper amp A M Sheridan Eds) Retrieved from UpToDate httpswww-uptodate-comproxywichitaeducontentstreatment-of-anemia-in-nondialysis-chronic-kidney-disease
bull Chan M Dall A T Fletcher K E Lu N amp Trivedi H (2007) Outcomes in patients with chronic kidney disease referred late to nephrologists a meta-analysis American Journal of Medicine 120(12) 1063-1070
bull Coresh J Selvin E amp Stevens L A (2007) Prevalence of chronic kidny disease in the United States JAMA 298(17) doi101001jama298172038
bull de Brito-Ashurst I Varagunam M Raftery M amp Yagoob M (2009) Bicarbonate supplementation slows progression of CKD and improves nutritional status Journal of American Society of Nephrology (20) 2075-2084
BIBLIOGRAPHY
bull Duncan L Heathcoat J Djurdjev O amp Levin A (2001) Screening for renal disease using serum creatinine who are we missing Nephrology Dialysis and Transplant 16(5) 1042-1046
bull Dunkler D Gao P Lee S F Heinz G Clase C M Tobe S Oberbauer R (2015 August 7) Risk prediction for early CKD in type 2 diabetes Retrieved from Clinical Journal of the American Society of Nephrology httpcjasnasnjournalsorgcontent1081371fullsid=61422554-a5f1-41ac-b696-dcd3b12bd268
bull Fatehi P amp Chi-yuan H (September 15 2016) Diagnostic approach to the patient with newly identified chronic kidney disease (G C Curhan amp A M Sheridan Eds) Retrieved May 7 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsdiagnostic-approach-to-the-patient-with-newly-identified-chronic-kidney-disease
bull Fink J e (2009) Chronic Kidney Disease as an Under-Recognized Threat to Patient Safety American journal of kidney diseases the official journal of the National Kidney Foundation 53(4) 681-688
bull Gaffo A L amp Saag K G (2008 Nov) Management of hyperuricemia and gout in CKD doihttpdxdoiorg101053jajkd200807035
bull Hebert L A amp Parikh S V (2014 June 18) Differential diagnosis and evaluation of glomerular disease (R J Glassock amp A Q Lam Eds) Retrieved May 7 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsdifferential-diagnosis-and-evaluation-of-glomerular-disease
bull Inker L Perrone R D Sterns R H amp Forman J P (2017 March 7) Assessment of kidney function Retrieved from UpToDate httpswww-uptodate-comproxywichitaeducontentsassessment-of-kidney-functionsource=search_resultampsearch=creatinineampselectedTitle=1~150
BIBLIOGRAPHY
bull James P A Ortiz E amp Et Al (2014) Evidence based guideline for the management of high blood pressure in adults (JNC) JAMA 311(5) 507-520
bull Kidney Disease Improving Global Outcomes (KDIGO) CKD Work Group (2013 January) KDIGO 2012 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease Retrieved from Kidney International Supplement httpwwwkidney-internationalorg
bull Kunz R Friedrich C Wolbers M amp Mann J F (2008) Meta-analysis effect of monotherapy and combination therapy with inhibitors of the renin angiotensin system on proteinuria in renal disease Annals of Internal Medicine 148(1) 30-48
bull Levey A Stevens L A Schmid C H Castro A F Feldman H I Kusek J W Coresh J (2009) A new equation to estimate glomerular filtration rate Annals of Internal Medicine 150(9) 604-612
bull Levin A Bakris G L Molitch M Smulders M M Williams L A amp Andress D L (2007 Jan) Prevalence of abnormal serum vitamin D PTH calcium and phosphorus in patients with chronic kidney disease results of the study to evaluate early kidney disease Kidney International 71(1) 31-38 Retrieved from PubMED
bull Mahajan A Simoni J Sheather S Broglio K Rajab M amp Wesson D (2010) Daily oral sodium bicarbonate preserves glomerular filtration rate by slowing its decline in early hypertensive nephropathy Kidney International (78_ 303-309
bull Mann J Schmieder R E amp McQueen M (2008) Renal outcomes with telmisartan ramipril or both in people at high vascular risk (the ONTARGET study) a multicentre randomised doubleblind ocntrolled trial Lancet 372(9638) 547-533
BIBLIOGRAPHY
bull Matovinović M S (2009) Pathophysiology and classification of kidney disease Retrieved from The Journal of the International Federation of Clinical Chemistry and Laboratory Medicine httpwwwifccorgifccfilesdocs20010902pdf
bull Moe S Drueke T Lameire N amp Eknoyan G (2007 Jan) Chronic kidney disease-mineral-bone disorder a new paradigmdoi101053jackd200610005
bull Murtagh F E Marsh J E Donohoe P Ekbal N J Sheerin N S amp Harris F E (2007 July) Dialysis or not A comparative survival study of patients over 75 years with chronic kidney disease stage 5 Retrieved from Nephrology Dialysis and Transplant 22(7) httpswwwncbinlmnihgovpubmed17412702
bull National Kidney Foundation (2002) KDOQI clinical practice guidelines for chronic kidney disease evaluation classification andstratification American Journal of Kidney Disease S1-S266
bull National Kidney Foundation (2014 November 5) Fact Sheets Retrieved from httpwwwkidneyorgnewsnewsroomfactsheetsFastFacts
bull Pal S (2012 June 2) Trends in chronic kidney disease Retrieved from US Pharmacist (37)6 httpswwwuspharmacistcomarticletrends-in-chronic-kidney-disease
bull Qunibi W amp Henrich W L (2017 Jan 19) Overview of chronic kidney disease-mineral and bone disorder (J Berns amp A M Sheridan Eds) Retrieved from UpToDate httpswww-uptodate-comoverview-of-chronic-kidney-disease-mineral-and-bone-disorder-ckd-mbd
bull Rosenberg M (2016 Feb 24) Overview of the management of chronic kidney disease in adults (G C Curhan amp A M Sheridan Eds) Retrieved from UpToDate UpToDate httpswww-uptodate-comproxywichitaeducontentsoverview-of-the-management-of-chronic-kidney-disease-in-adults
BIBLIOGRAPHY
bull Szczech L Stewart R C Hsu-Lin S DeLosky R J Astor B C Fox C H Vassalotti J A (2014) Primary care detection of chronic kidney disease in adults with type 2 diabetes The ADD-CKD Study (Awareness Detection and Drug Therapy in type 2 diabetes and chronic kidney disease PLOS doihttpsdoiorg101371journalpone0110535
bull USRDS (2016) Annual data report 2016 Epidemiology of kidney disease in the United States Retrieved from United States Renal Data System httpswwwusrdsorgadraspx
bull Vasudev B amp Vasudev M (2012) A model curriculum for residents rotating in nephrology MedEDPORTAL doihttpdoiorg1015766mep_2374-82658288
bull Wei L MacDonald T M Jennings C Sheng X amp Flynn R W (2013) Estimated GFR reporting is associated with decreased nonsteroidal anti-inflammatory drug prescribing and increased renal function Kidney International (84)1 174-178
chronic kidney disease in primary care
CKD as a Public Health Issue
Slide Number 3
Costs of CKD in 2013 dollarsUSRDS report
Steps to CKD Patient Care
Renal anatomy and physiology
Definition of Chronic Kidney Disease
CKD Risk Factors
Gaps in CKD Diagnosis
Slide Number 10
Steps to CKD Patient Care
creatinine
Glomerular filtration rate
Slide Number 14
Slide Number 15
Use These Equations Cautiously if at all in hellip
lab albumin creatinine ratio
The New CKD Categories
Steps to CKD Patient Care
Slide Number 20
Kidney Involvement in Systemic Diseases
Slide Number 22
Slide Number 23
DysmorphicRenal Hematuria
Slide Number 25
If you have albuminuria or hematuria-order the following labs
Prevalence of Abnormalities of Mineral Metabolism PTH in CKD
Managing CKD-MBD complications
CKD-MBD Testing
Anemia Becomes More Common as Kidney Function Declines
Detect and Manage CKD Complications
Complications-metabolic acidosis
Complications-vascular calcification
Hyperkalemia management
Hyperuricemia levels amp CKD
CKD monitoring levels 345
Slide Number 59
When to Refer to a Nephrologist
When to Refer
Steps to CKD Patient Care
Kidney transplantation
Starting Dialysis in the ElderlyhellipOr Not
Ckd management
Case 1
Slide Number 67
Lab results
Slide Number 69
Hypertensive nephropathy with proteinuria
Slide Number 71
Case 2
Slide Number 73
Management of CKD in Diabetes
Case 3
Case 3
Systemic Lupus Erythematosus (SLE)
SLE ndash Lupus Nephritis
Case 5
Case 5
Slide Number 81
Slide Number 82
Case study
Slide Number 84
CXR ndash Hilar Lymphadenopathy
Whats needed next
Slide Number 87
newly dx ckd
Slide Number 89
Bibliography
bibliography
bibliography
bibliography
bibliography
CASE 1
bull 55 year old man with past medical history of headaches presents to your office for his first time visit to a PCP in over 30 years
bull He has no past history of being admitted to the hospital and he does not take any OTC medsNSAIDsherbal meds He has no history of ETOH abuse smoking or drug use
bull Vitals BP 180100 mmHg pulse 80 R 18
bull Exam No JVD S1S2 regular PMI shifted to the left no gallop no abdominal bruit pulses bilaterally equal and regular no leg edema
bull What would you order
bull EKG cbc cmp ua urine proteincr ratio lipid
LAB RESULTS
bull Labs reveal a creatinine of 22 mgdL eGFR 33 Urine shows no blood or casts Urineprotein ratio shows 1 gm protein24 hrs EKG shows LVH
bull Next step in workupbull Renal ultrasound 1st then SPEP UPEP with immunofixation serum free light chains
bull Additional labs neg Renal ultrasound shows that both kidneys are slightly reduced in size and are mildly echogenic with no mass or hydronephrosis
bull What is your diagnosis
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileMain_complications_of_persistent_high_blood_pressurepngCreative Commons License associated httpcreativecommonsorglicensesby-sa30
bull 3 months Howevermdashwe have evidence of structural abnormalities Could potentially stage at G3b A3 (red on the heat map)
bull Goal blood pressure
bull JNC 8 14090 NKF 13080
bull Additional lab needed for progression monitoring
bull Cbc renal panel phos Vit D iPTH uric acid urine micro (we already have the renal sono and urine proteincr ratio and lipid)
Selective renal angiography (left lower renal artery) after successful percutaneous balloon dilatation of the stenotic lesionFibromuscular dysplasia in an accessory renal artery causing renovascular hypertension
Secondary Hypertension
Images retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileRenal_FMD2jpg and httpcommonswikimediaorgwikiFileRenal_FMDjpgCreative Commons License associated httpcreativecommonsorglicensesby20deeden (both images)
CASE 2bull OS is a 64year old Hispanic female in for DM check She has had DM for 15+ years and is currently
taking metformin 1000mg bid Lisinopril 10mg a day atorvastatin 40mg a day Labs today showed the following
bull Hgba1c 86 cmp eGFR 50 lipid WNL proteincr ratio 650mg These results are similar to her last visit
bull Upon further hx-you find that she had a recent eye exam and has mild nonproliferaive retinopathy She does not have neuropathy or other ss
bull What further workup do you need
bull Renal sonogram urine micro iPTH vit D (25 OH) phos uric acid
bull Dx stage
bull G3a A3
bull What further treatment do you need
bull Improve glycemic control Increase Lisinopril to 20mg with a goal of 40mg Avoid NSAIDs or other nephrotoxic agents make sure meds are renally dosed monitor 3xyear nephro referral
MANAGEMENT OF CKD IN DIABETESeGFR Recommended
All patients
Yearly measurement of creatinine urinary albumin excretion potassium
45-60 Referral to a nephrologist if possibility for nondiabetickidney disease existsConsider dose adjustment of medicationsMonitor eGFR every 6 monthsMonitor electrolytes bicarbonate hemoglobin calcium phosphorus parathyroid hormone at least yearly
Assure vitamin D sufficiencyConsider bone density testingReferral for dietary counselling
American Diabetes Association Standards of Medical Care in Diabetes Microvascular complications and foot care Diabetes Care 2017 40 (Suppl 1) S88-S98
CASE 3
bull 19 year old African American woman presents to your clinic with complaints of fatigue joint pains a new rash on her face oral ulcer
bull On exam BP 15080 P 88 Afebrile 96 O2 sats on RAbull GEN No respiratory distress at restbull HEENT painless oral ulcer flat rash over malar eminences sparing the nasolabial fold pallor +bull Lungs CTAbull CVS S1S2 regularbull Abdomen soft NTbull Ext left elbow joint and bilateral wrist joints are swollen and tender
bull What would you orderbull CBC CMP ua urine microscopy (microalbumin or urine proteincr ratio) ANA esr RF anti-ccp uric acid TSH
CASE 3
bull Working dx fatigue oral ulcer joint pain
bull Basic Labs Na 135 K 55 Bicarb 18 BUN 50 Cr 35 eGFR 22 Ca 90 ANA + titer 1640
bull UA 3+ blood 3+ protein RBC casts +
bull Given these results what is the most likely diagnosis
bull What would you do
SYSTEMIC LUPUS ERYTHEMATOSUS (SLE)
bull SLE multisystemic disease Etiology unknown
bull Production of autoantibodies and immune complexes formation
bull There is renal involvement in the great majority of patients with SLE at some time of the evolution 66-90
SLE ndash LUPUS NEPHRITIS
bull Race SLE is more commonsevere in African americans than Caucasiansbull
bull Gender female-to-male ratio of 91
bull Age Most patients develop lupus nephritis early in their disease course SLE is more common among women in the third decade of life and lupus nephritis occurs in patients aged 20-40 years
bull Kidney Biopsy For staging lupus nephritis (Class 1-5)
CASE 5bull A 80 year old man who has not seen a PCP in many years
presents to your clinic for weakness for the past few months On further questioning he tells you that his bones also have been hurting lately and he has developed leg swelling in the past month or so
bull On exam bull BP 16090 P 88 Afebrilebull GEN Thin built manbull HEENT pallor presentbull Lungs clearbull CVS S1S2 regular no rub or gallopbull Abdomen soft NTbull Ext 2 + edema
CASE 5
bull Differentials
bull CHF MI Cancer arthritis
bull Labs
bull CBC CMP urine microscopy urine proteincr ratio ESR TSH EKG BNP pa and lat CXR
bull LABS Urine dipstick negative for protein or blood
bull Basic chem bull Na 136 (135-145) K 51 (35-55) Chloride 108 (96-106) Bicarb 25
Given this presentation and the labs (low anion gap and elevated calcium anemia kidney failure) what will you think of What will you order next
Serum and urine protein electrophoresis
Intratubular refractile casts with surrounding syncytial giant cell reaction with chronic tubulointerstitial nephritis and fibrosis characteristic of myeloma cast nephropathy
Kidney Biopsy
CASE STUDYbull A 35 year old African American woman was seen in the clinic for
chronic cough and dyspnea on exertion She gave history of vague symptoms of fatigue and weight loss of 20 Ibs over the last six months
bull List some differentialsbull TB sarcoid lupus thyroid problems PEbull What would you orderbull PPD cbc cmp UA TSH ANA pa and lat cxr
bull Her labs were significant for mildly elevated calcium level and a creatinine of 20 mgdL eGFR 37
bull She had 750 mg of proteinuriaday
bull PPD neg ANA neg TSH and other labs WNL
bull Assuming this is present more than 3 monthshelliphellipwhat is her ckd stage
bull G3b A3
bull What do we still need
CT scan of chest
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileAnterior_mediastinal_mass_thymomajpgCreative Commons License associated httpcreativecommonsorglicensesby20deeden
CXR ndash HILAR LYMPHADENOPATHY
WHATS NEEDED NEXT
bull Biopsy of hilar lymphadenopathy or renal biopsy
bull DX sarcoidosis
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileSarcoidosis_signs_and_symptomsjpgThis work is in the public domain in the United States because it is a work of the United States Federal Government under the terms of Title 17 Chapter 1 Section 105 of the US Code
NEWLY DX CKD
bull 1) urinalysis microscopy ultrasound proteincr ratio
bull If obstruction-treat
bull No obstruction
bull Hx critical (consider myeloma if high risk)
bull glomerular bleeding or albumin in urine
bull Yes workup for glomerular causes (ANArf hep B C upep spep ANCA complement C3 C4)
bull No sterile pyruria-consider interstitial nephritis
bull High risk renovascular disease Evaluate renovascular disease
Additional Online Resources for CKD LearningbullNational Kidney Foundation wwwkidneyorgbullUnited States Renal Data Service wwwusrdsorgbullCDCrsquos CKD Surveillance Project
httpnccdcdcgovckdbullNational Kidney Disease Education Program
(NKDEP) httpnkdepnihgov
BIBLIOGRAPHY
bull Afzali B amp Goldsmith D J (2016 June 29) Statins and chronic kidney disease (G C Curhan amp A M Sheridan Eds) Retrieved 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsstatins-and-chronic-kidney-disease
bull American Diabetes Association Standards of Medical Care in Diabetes (2017) Microvascular complications and foot care Diabetes Care 2017 (40) S88-S98
bull American Diabetes Association Standards of Medical Care in Diabetes (2017) Microvascular complications and foot care Diabetes Care 40 (suppl 1) S88-S98
bull Berns J S (2017 Mar 22) Treatment of anemia in nondialysis chronic kidney disease (T A Golper amp A M Sheridan Eds) Retrieved from UpToDate httpswww-uptodate-comproxywichitaeducontentstreatment-of-anemia-in-nondialysis-chronic-kidney-disease
bull Chan M Dall A T Fletcher K E Lu N amp Trivedi H (2007) Outcomes in patients with chronic kidney disease referred late to nephrologists a meta-analysis American Journal of Medicine 120(12) 1063-1070
bull Coresh J Selvin E amp Stevens L A (2007) Prevalence of chronic kidny disease in the United States JAMA 298(17) doi101001jama298172038
bull de Brito-Ashurst I Varagunam M Raftery M amp Yagoob M (2009) Bicarbonate supplementation slows progression of CKD and improves nutritional status Journal of American Society of Nephrology (20) 2075-2084
BIBLIOGRAPHY
bull Duncan L Heathcoat J Djurdjev O amp Levin A (2001) Screening for renal disease using serum creatinine who are we missing Nephrology Dialysis and Transplant 16(5) 1042-1046
bull Dunkler D Gao P Lee S F Heinz G Clase C M Tobe S Oberbauer R (2015 August 7) Risk prediction for early CKD in type 2 diabetes Retrieved from Clinical Journal of the American Society of Nephrology httpcjasnasnjournalsorgcontent1081371fullsid=61422554-a5f1-41ac-b696-dcd3b12bd268
bull Fatehi P amp Chi-yuan H (September 15 2016) Diagnostic approach to the patient with newly identified chronic kidney disease (G C Curhan amp A M Sheridan Eds) Retrieved May 7 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsdiagnostic-approach-to-the-patient-with-newly-identified-chronic-kidney-disease
bull Fink J e (2009) Chronic Kidney Disease as an Under-Recognized Threat to Patient Safety American journal of kidney diseases the official journal of the National Kidney Foundation 53(4) 681-688
bull Gaffo A L amp Saag K G (2008 Nov) Management of hyperuricemia and gout in CKD doihttpdxdoiorg101053jajkd200807035
bull Hebert L A amp Parikh S V (2014 June 18) Differential diagnosis and evaluation of glomerular disease (R J Glassock amp A Q Lam Eds) Retrieved May 7 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsdifferential-diagnosis-and-evaluation-of-glomerular-disease
bull Inker L Perrone R D Sterns R H amp Forman J P (2017 March 7) Assessment of kidney function Retrieved from UpToDate httpswww-uptodate-comproxywichitaeducontentsassessment-of-kidney-functionsource=search_resultampsearch=creatinineampselectedTitle=1~150
BIBLIOGRAPHY
bull James P A Ortiz E amp Et Al (2014) Evidence based guideline for the management of high blood pressure in adults (JNC) JAMA 311(5) 507-520
bull Kidney Disease Improving Global Outcomes (KDIGO) CKD Work Group (2013 January) KDIGO 2012 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease Retrieved from Kidney International Supplement httpwwwkidney-internationalorg
bull Kunz R Friedrich C Wolbers M amp Mann J F (2008) Meta-analysis effect of monotherapy and combination therapy with inhibitors of the renin angiotensin system on proteinuria in renal disease Annals of Internal Medicine 148(1) 30-48
bull Levey A Stevens L A Schmid C H Castro A F Feldman H I Kusek J W Coresh J (2009) A new equation to estimate glomerular filtration rate Annals of Internal Medicine 150(9) 604-612
bull Levin A Bakris G L Molitch M Smulders M M Williams L A amp Andress D L (2007 Jan) Prevalence of abnormal serum vitamin D PTH calcium and phosphorus in patients with chronic kidney disease results of the study to evaluate early kidney disease Kidney International 71(1) 31-38 Retrieved from PubMED
bull Mahajan A Simoni J Sheather S Broglio K Rajab M amp Wesson D (2010) Daily oral sodium bicarbonate preserves glomerular filtration rate by slowing its decline in early hypertensive nephropathy Kidney International (78_ 303-309
bull Mann J Schmieder R E amp McQueen M (2008) Renal outcomes with telmisartan ramipril or both in people at high vascular risk (the ONTARGET study) a multicentre randomised doubleblind ocntrolled trial Lancet 372(9638) 547-533
BIBLIOGRAPHY
bull Matovinović M S (2009) Pathophysiology and classification of kidney disease Retrieved from The Journal of the International Federation of Clinical Chemistry and Laboratory Medicine httpwwwifccorgifccfilesdocs20010902pdf
bull Moe S Drueke T Lameire N amp Eknoyan G (2007 Jan) Chronic kidney disease-mineral-bone disorder a new paradigmdoi101053jackd200610005
bull Murtagh F E Marsh J E Donohoe P Ekbal N J Sheerin N S amp Harris F E (2007 July) Dialysis or not A comparative survival study of patients over 75 years with chronic kidney disease stage 5 Retrieved from Nephrology Dialysis and Transplant 22(7) httpswwwncbinlmnihgovpubmed17412702
bull National Kidney Foundation (2002) KDOQI clinical practice guidelines for chronic kidney disease evaluation classification andstratification American Journal of Kidney Disease S1-S266
bull National Kidney Foundation (2014 November 5) Fact Sheets Retrieved from httpwwwkidneyorgnewsnewsroomfactsheetsFastFacts
bull Pal S (2012 June 2) Trends in chronic kidney disease Retrieved from US Pharmacist (37)6 httpswwwuspharmacistcomarticletrends-in-chronic-kidney-disease
bull Qunibi W amp Henrich W L (2017 Jan 19) Overview of chronic kidney disease-mineral and bone disorder (J Berns amp A M Sheridan Eds) Retrieved from UpToDate httpswww-uptodate-comoverview-of-chronic-kidney-disease-mineral-and-bone-disorder-ckd-mbd
bull Rosenberg M (2016 Feb 24) Overview of the management of chronic kidney disease in adults (G C Curhan amp A M Sheridan Eds) Retrieved from UpToDate UpToDate httpswww-uptodate-comproxywichitaeducontentsoverview-of-the-management-of-chronic-kidney-disease-in-adults
BIBLIOGRAPHY
bull Szczech L Stewart R C Hsu-Lin S DeLosky R J Astor B C Fox C H Vassalotti J A (2014) Primary care detection of chronic kidney disease in adults with type 2 diabetes The ADD-CKD Study (Awareness Detection and Drug Therapy in type 2 diabetes and chronic kidney disease PLOS doihttpsdoiorg101371journalpone0110535
bull USRDS (2016) Annual data report 2016 Epidemiology of kidney disease in the United States Retrieved from United States Renal Data System httpswwwusrdsorgadraspx
bull Vasudev B amp Vasudev M (2012) A model curriculum for residents rotating in nephrology MedEDPORTAL doihttpdoiorg1015766mep_2374-82658288
bull Wei L MacDonald T M Jennings C Sheng X amp Flynn R W (2013) Estimated GFR reporting is associated with decreased nonsteroidal anti-inflammatory drug prescribing and increased renal function Kidney International (84)1 174-178
chronic kidney disease in primary care
CKD as a Public Health Issue
Slide Number 3
Costs of CKD in 2013 dollarsUSRDS report
Steps to CKD Patient Care
Renal anatomy and physiology
Definition of Chronic Kidney Disease
CKD Risk Factors
Gaps in CKD Diagnosis
Slide Number 10
Steps to CKD Patient Care
creatinine
Glomerular filtration rate
Slide Number 14
Slide Number 15
Use These Equations Cautiously if at all in hellip
lab albumin creatinine ratio
The New CKD Categories
Steps to CKD Patient Care
Slide Number 20
Kidney Involvement in Systemic Diseases
Slide Number 22
Slide Number 23
DysmorphicRenal Hematuria
Slide Number 25
If you have albuminuria or hematuria-order the following labs
Prevalence of Abnormalities of Mineral Metabolism PTH in CKD
Managing CKD-MBD complications
CKD-MBD Testing
Anemia Becomes More Common as Kidney Function Declines
Detect and Manage CKD Complications
Complications-metabolic acidosis
Complications-vascular calcification
Hyperkalemia management
Hyperuricemia levels amp CKD
CKD monitoring levels 345
Slide Number 59
When to Refer to a Nephrologist
When to Refer
Steps to CKD Patient Care
Kidney transplantation
Starting Dialysis in the ElderlyhellipOr Not
Ckd management
Case 1
Slide Number 67
Lab results
Slide Number 69
Hypertensive nephropathy with proteinuria
Slide Number 71
Case 2
Slide Number 73
Management of CKD in Diabetes
Case 3
Case 3
Systemic Lupus Erythematosus (SLE)
SLE ndash Lupus Nephritis
Case 5
Case 5
Slide Number 81
Slide Number 82
Case study
Slide Number 84
CXR ndash Hilar Lymphadenopathy
Whats needed next
Slide Number 87
newly dx ckd
Slide Number 89
Bibliography
bibliography
bibliography
bibliography
bibliography
bull Vitals BP 180100 mmHg pulse 80 R 18
bull Exam No JVD S1S2 regular PMI shifted to the left no gallop no abdominal bruit pulses bilaterally equal and regular no leg edema
bull What would you order
bull EKG cbc cmp ua urine proteincr ratio lipid
LAB RESULTS
bull Labs reveal a creatinine of 22 mgdL eGFR 33 Urine shows no blood or casts Urineprotein ratio shows 1 gm protein24 hrs EKG shows LVH
bull Next step in workupbull Renal ultrasound 1st then SPEP UPEP with immunofixation serum free light chains
bull Additional labs neg Renal ultrasound shows that both kidneys are slightly reduced in size and are mildly echogenic with no mass or hydronephrosis
bull What is your diagnosis
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileMain_complications_of_persistent_high_blood_pressurepngCreative Commons License associated httpcreativecommonsorglicensesby-sa30
bull 3 months Howevermdashwe have evidence of structural abnormalities Could potentially stage at G3b A3 (red on the heat map)
bull Goal blood pressure
bull JNC 8 14090 NKF 13080
bull Additional lab needed for progression monitoring
bull Cbc renal panel phos Vit D iPTH uric acid urine micro (we already have the renal sono and urine proteincr ratio and lipid)
Selective renal angiography (left lower renal artery) after successful percutaneous balloon dilatation of the stenotic lesionFibromuscular dysplasia in an accessory renal artery causing renovascular hypertension
Secondary Hypertension
Images retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileRenal_FMD2jpg and httpcommonswikimediaorgwikiFileRenal_FMDjpgCreative Commons License associated httpcreativecommonsorglicensesby20deeden (both images)
CASE 2bull OS is a 64year old Hispanic female in for DM check She has had DM for 15+ years and is currently
taking metformin 1000mg bid Lisinopril 10mg a day atorvastatin 40mg a day Labs today showed the following
bull Hgba1c 86 cmp eGFR 50 lipid WNL proteincr ratio 650mg These results are similar to her last visit
bull Upon further hx-you find that she had a recent eye exam and has mild nonproliferaive retinopathy She does not have neuropathy or other ss
bull What further workup do you need
bull Renal sonogram urine micro iPTH vit D (25 OH) phos uric acid
bull Dx stage
bull G3a A3
bull What further treatment do you need
bull Improve glycemic control Increase Lisinopril to 20mg with a goal of 40mg Avoid NSAIDs or other nephrotoxic agents make sure meds are renally dosed monitor 3xyear nephro referral
MANAGEMENT OF CKD IN DIABETESeGFR Recommended
All patients
Yearly measurement of creatinine urinary albumin excretion potassium
45-60 Referral to a nephrologist if possibility for nondiabetickidney disease existsConsider dose adjustment of medicationsMonitor eGFR every 6 monthsMonitor electrolytes bicarbonate hemoglobin calcium phosphorus parathyroid hormone at least yearly
Assure vitamin D sufficiencyConsider bone density testingReferral for dietary counselling
American Diabetes Association Standards of Medical Care in Diabetes Microvascular complications and foot care Diabetes Care 2017 40 (Suppl 1) S88-S98
CASE 3
bull 19 year old African American woman presents to your clinic with complaints of fatigue joint pains a new rash on her face oral ulcer
bull On exam BP 15080 P 88 Afebrile 96 O2 sats on RAbull GEN No respiratory distress at restbull HEENT painless oral ulcer flat rash over malar eminences sparing the nasolabial fold pallor +bull Lungs CTAbull CVS S1S2 regularbull Abdomen soft NTbull Ext left elbow joint and bilateral wrist joints are swollen and tender
bull What would you orderbull CBC CMP ua urine microscopy (microalbumin or urine proteincr ratio) ANA esr RF anti-ccp uric acid TSH
CASE 3
bull Working dx fatigue oral ulcer joint pain
bull Basic Labs Na 135 K 55 Bicarb 18 BUN 50 Cr 35 eGFR 22 Ca 90 ANA + titer 1640
bull UA 3+ blood 3+ protein RBC casts +
bull Given these results what is the most likely diagnosis
bull What would you do
SYSTEMIC LUPUS ERYTHEMATOSUS (SLE)
bull SLE multisystemic disease Etiology unknown
bull Production of autoantibodies and immune complexes formation
bull There is renal involvement in the great majority of patients with SLE at some time of the evolution 66-90
SLE ndash LUPUS NEPHRITIS
bull Race SLE is more commonsevere in African americans than Caucasiansbull
bull Gender female-to-male ratio of 91
bull Age Most patients develop lupus nephritis early in their disease course SLE is more common among women in the third decade of life and lupus nephritis occurs in patients aged 20-40 years
bull Kidney Biopsy For staging lupus nephritis (Class 1-5)
CASE 5bull A 80 year old man who has not seen a PCP in many years
presents to your clinic for weakness for the past few months On further questioning he tells you that his bones also have been hurting lately and he has developed leg swelling in the past month or so
bull On exam bull BP 16090 P 88 Afebrilebull GEN Thin built manbull HEENT pallor presentbull Lungs clearbull CVS S1S2 regular no rub or gallopbull Abdomen soft NTbull Ext 2 + edema
CASE 5
bull Differentials
bull CHF MI Cancer arthritis
bull Labs
bull CBC CMP urine microscopy urine proteincr ratio ESR TSH EKG BNP pa and lat CXR
bull LABS Urine dipstick negative for protein or blood
bull Basic chem bull Na 136 (135-145) K 51 (35-55) Chloride 108 (96-106) Bicarb 25
Given this presentation and the labs (low anion gap and elevated calcium anemia kidney failure) what will you think of What will you order next
Serum and urine protein electrophoresis
Intratubular refractile casts with surrounding syncytial giant cell reaction with chronic tubulointerstitial nephritis and fibrosis characteristic of myeloma cast nephropathy
Kidney Biopsy
CASE STUDYbull A 35 year old African American woman was seen in the clinic for
chronic cough and dyspnea on exertion She gave history of vague symptoms of fatigue and weight loss of 20 Ibs over the last six months
bull List some differentialsbull TB sarcoid lupus thyroid problems PEbull What would you orderbull PPD cbc cmp UA TSH ANA pa and lat cxr
bull Her labs were significant for mildly elevated calcium level and a creatinine of 20 mgdL eGFR 37
bull She had 750 mg of proteinuriaday
bull PPD neg ANA neg TSH and other labs WNL
bull Assuming this is present more than 3 monthshelliphellipwhat is her ckd stage
bull G3b A3
bull What do we still need
CT scan of chest
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileAnterior_mediastinal_mass_thymomajpgCreative Commons License associated httpcreativecommonsorglicensesby20deeden
CXR ndash HILAR LYMPHADENOPATHY
WHATS NEEDED NEXT
bull Biopsy of hilar lymphadenopathy or renal biopsy
bull DX sarcoidosis
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileSarcoidosis_signs_and_symptomsjpgThis work is in the public domain in the United States because it is a work of the United States Federal Government under the terms of Title 17 Chapter 1 Section 105 of the US Code
NEWLY DX CKD
bull 1) urinalysis microscopy ultrasound proteincr ratio
bull If obstruction-treat
bull No obstruction
bull Hx critical (consider myeloma if high risk)
bull glomerular bleeding or albumin in urine
bull Yes workup for glomerular causes (ANArf hep B C upep spep ANCA complement C3 C4)
bull No sterile pyruria-consider interstitial nephritis
bull High risk renovascular disease Evaluate renovascular disease
Additional Online Resources for CKD LearningbullNational Kidney Foundation wwwkidneyorgbullUnited States Renal Data Service wwwusrdsorgbullCDCrsquos CKD Surveillance Project
httpnccdcdcgovckdbullNational Kidney Disease Education Program
(NKDEP) httpnkdepnihgov
BIBLIOGRAPHY
bull Afzali B amp Goldsmith D J (2016 June 29) Statins and chronic kidney disease (G C Curhan amp A M Sheridan Eds) Retrieved 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsstatins-and-chronic-kidney-disease
bull American Diabetes Association Standards of Medical Care in Diabetes (2017) Microvascular complications and foot care Diabetes Care 2017 (40) S88-S98
bull American Diabetes Association Standards of Medical Care in Diabetes (2017) Microvascular complications and foot care Diabetes Care 40 (suppl 1) S88-S98
bull Berns J S (2017 Mar 22) Treatment of anemia in nondialysis chronic kidney disease (T A Golper amp A M Sheridan Eds) Retrieved from UpToDate httpswww-uptodate-comproxywichitaeducontentstreatment-of-anemia-in-nondialysis-chronic-kidney-disease
bull Chan M Dall A T Fletcher K E Lu N amp Trivedi H (2007) Outcomes in patients with chronic kidney disease referred late to nephrologists a meta-analysis American Journal of Medicine 120(12) 1063-1070
bull Coresh J Selvin E amp Stevens L A (2007) Prevalence of chronic kidny disease in the United States JAMA 298(17) doi101001jama298172038
bull de Brito-Ashurst I Varagunam M Raftery M amp Yagoob M (2009) Bicarbonate supplementation slows progression of CKD and improves nutritional status Journal of American Society of Nephrology (20) 2075-2084
BIBLIOGRAPHY
bull Duncan L Heathcoat J Djurdjev O amp Levin A (2001) Screening for renal disease using serum creatinine who are we missing Nephrology Dialysis and Transplant 16(5) 1042-1046
bull Dunkler D Gao P Lee S F Heinz G Clase C M Tobe S Oberbauer R (2015 August 7) Risk prediction for early CKD in type 2 diabetes Retrieved from Clinical Journal of the American Society of Nephrology httpcjasnasnjournalsorgcontent1081371fullsid=61422554-a5f1-41ac-b696-dcd3b12bd268
bull Fatehi P amp Chi-yuan H (September 15 2016) Diagnostic approach to the patient with newly identified chronic kidney disease (G C Curhan amp A M Sheridan Eds) Retrieved May 7 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsdiagnostic-approach-to-the-patient-with-newly-identified-chronic-kidney-disease
bull Fink J e (2009) Chronic Kidney Disease as an Under-Recognized Threat to Patient Safety American journal of kidney diseases the official journal of the National Kidney Foundation 53(4) 681-688
bull Gaffo A L amp Saag K G (2008 Nov) Management of hyperuricemia and gout in CKD doihttpdxdoiorg101053jajkd200807035
bull Hebert L A amp Parikh S V (2014 June 18) Differential diagnosis and evaluation of glomerular disease (R J Glassock amp A Q Lam Eds) Retrieved May 7 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsdifferential-diagnosis-and-evaluation-of-glomerular-disease
bull Inker L Perrone R D Sterns R H amp Forman J P (2017 March 7) Assessment of kidney function Retrieved from UpToDate httpswww-uptodate-comproxywichitaeducontentsassessment-of-kidney-functionsource=search_resultampsearch=creatinineampselectedTitle=1~150
BIBLIOGRAPHY
bull James P A Ortiz E amp Et Al (2014) Evidence based guideline for the management of high blood pressure in adults (JNC) JAMA 311(5) 507-520
bull Kidney Disease Improving Global Outcomes (KDIGO) CKD Work Group (2013 January) KDIGO 2012 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease Retrieved from Kidney International Supplement httpwwwkidney-internationalorg
bull Kunz R Friedrich C Wolbers M amp Mann J F (2008) Meta-analysis effect of monotherapy and combination therapy with inhibitors of the renin angiotensin system on proteinuria in renal disease Annals of Internal Medicine 148(1) 30-48
bull Levey A Stevens L A Schmid C H Castro A F Feldman H I Kusek J W Coresh J (2009) A new equation to estimate glomerular filtration rate Annals of Internal Medicine 150(9) 604-612
bull Levin A Bakris G L Molitch M Smulders M M Williams L A amp Andress D L (2007 Jan) Prevalence of abnormal serum vitamin D PTH calcium and phosphorus in patients with chronic kidney disease results of the study to evaluate early kidney disease Kidney International 71(1) 31-38 Retrieved from PubMED
bull Mahajan A Simoni J Sheather S Broglio K Rajab M amp Wesson D (2010) Daily oral sodium bicarbonate preserves glomerular filtration rate by slowing its decline in early hypertensive nephropathy Kidney International (78_ 303-309
bull Mann J Schmieder R E amp McQueen M (2008) Renal outcomes with telmisartan ramipril or both in people at high vascular risk (the ONTARGET study) a multicentre randomised doubleblind ocntrolled trial Lancet 372(9638) 547-533
BIBLIOGRAPHY
bull Matovinović M S (2009) Pathophysiology and classification of kidney disease Retrieved from The Journal of the International Federation of Clinical Chemistry and Laboratory Medicine httpwwwifccorgifccfilesdocs20010902pdf
bull Moe S Drueke T Lameire N amp Eknoyan G (2007 Jan) Chronic kidney disease-mineral-bone disorder a new paradigmdoi101053jackd200610005
bull Murtagh F E Marsh J E Donohoe P Ekbal N J Sheerin N S amp Harris F E (2007 July) Dialysis or not A comparative survival study of patients over 75 years with chronic kidney disease stage 5 Retrieved from Nephrology Dialysis and Transplant 22(7) httpswwwncbinlmnihgovpubmed17412702
bull National Kidney Foundation (2002) KDOQI clinical practice guidelines for chronic kidney disease evaluation classification andstratification American Journal of Kidney Disease S1-S266
bull National Kidney Foundation (2014 November 5) Fact Sheets Retrieved from httpwwwkidneyorgnewsnewsroomfactsheetsFastFacts
bull Pal S (2012 June 2) Trends in chronic kidney disease Retrieved from US Pharmacist (37)6 httpswwwuspharmacistcomarticletrends-in-chronic-kidney-disease
bull Qunibi W amp Henrich W L (2017 Jan 19) Overview of chronic kidney disease-mineral and bone disorder (J Berns amp A M Sheridan Eds) Retrieved from UpToDate httpswww-uptodate-comoverview-of-chronic-kidney-disease-mineral-and-bone-disorder-ckd-mbd
bull Rosenberg M (2016 Feb 24) Overview of the management of chronic kidney disease in adults (G C Curhan amp A M Sheridan Eds) Retrieved from UpToDate UpToDate httpswww-uptodate-comproxywichitaeducontentsoverview-of-the-management-of-chronic-kidney-disease-in-adults
BIBLIOGRAPHY
bull Szczech L Stewart R C Hsu-Lin S DeLosky R J Astor B C Fox C H Vassalotti J A (2014) Primary care detection of chronic kidney disease in adults with type 2 diabetes The ADD-CKD Study (Awareness Detection and Drug Therapy in type 2 diabetes and chronic kidney disease PLOS doihttpsdoiorg101371journalpone0110535
bull USRDS (2016) Annual data report 2016 Epidemiology of kidney disease in the United States Retrieved from United States Renal Data System httpswwwusrdsorgadraspx
bull Vasudev B amp Vasudev M (2012) A model curriculum for residents rotating in nephrology MedEDPORTAL doihttpdoiorg1015766mep_2374-82658288
bull Wei L MacDonald T M Jennings C Sheng X amp Flynn R W (2013) Estimated GFR reporting is associated with decreased nonsteroidal anti-inflammatory drug prescribing and increased renal function Kidney International (84)1 174-178
chronic kidney disease in primary care
CKD as a Public Health Issue
Slide Number 3
Costs of CKD in 2013 dollarsUSRDS report
Steps to CKD Patient Care
Renal anatomy and physiology
Definition of Chronic Kidney Disease
CKD Risk Factors
Gaps in CKD Diagnosis
Slide Number 10
Steps to CKD Patient Care
creatinine
Glomerular filtration rate
Slide Number 14
Slide Number 15
Use These Equations Cautiously if at all in hellip
lab albumin creatinine ratio
The New CKD Categories
Steps to CKD Patient Care
Slide Number 20
Kidney Involvement in Systemic Diseases
Slide Number 22
Slide Number 23
DysmorphicRenal Hematuria
Slide Number 25
If you have albuminuria or hematuria-order the following labs
Prevalence of Abnormalities of Mineral Metabolism PTH in CKD
Managing CKD-MBD complications
CKD-MBD Testing
Anemia Becomes More Common as Kidney Function Declines
Detect and Manage CKD Complications
Complications-metabolic acidosis
Complications-vascular calcification
Hyperkalemia management
Hyperuricemia levels amp CKD
CKD monitoring levels 345
Slide Number 59
When to Refer to a Nephrologist
When to Refer
Steps to CKD Patient Care
Kidney transplantation
Starting Dialysis in the ElderlyhellipOr Not
Ckd management
Case 1
Slide Number 67
Lab results
Slide Number 69
Hypertensive nephropathy with proteinuria
Slide Number 71
Case 2
Slide Number 73
Management of CKD in Diabetes
Case 3
Case 3
Systemic Lupus Erythematosus (SLE)
SLE ndash Lupus Nephritis
Case 5
Case 5
Slide Number 81
Slide Number 82
Case study
Slide Number 84
CXR ndash Hilar Lymphadenopathy
Whats needed next
Slide Number 87
newly dx ckd
Slide Number 89
Bibliography
bibliography
bibliography
bibliography
bibliography
LAB RESULTS
bull Labs reveal a creatinine of 22 mgdL eGFR 33 Urine shows no blood or casts Urineprotein ratio shows 1 gm protein24 hrs EKG shows LVH
bull Next step in workupbull Renal ultrasound 1st then SPEP UPEP with immunofixation serum free light chains
bull Additional labs neg Renal ultrasound shows that both kidneys are slightly reduced in size and are mildly echogenic with no mass or hydronephrosis
bull What is your diagnosis
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileMain_complications_of_persistent_high_blood_pressurepngCreative Commons License associated httpcreativecommonsorglicensesby-sa30
bull 3 months Howevermdashwe have evidence of structural abnormalities Could potentially stage at G3b A3 (red on the heat map)
bull Goal blood pressure
bull JNC 8 14090 NKF 13080
bull Additional lab needed for progression monitoring
bull Cbc renal panel phos Vit D iPTH uric acid urine micro (we already have the renal sono and urine proteincr ratio and lipid)
Selective renal angiography (left lower renal artery) after successful percutaneous balloon dilatation of the stenotic lesionFibromuscular dysplasia in an accessory renal artery causing renovascular hypertension
Secondary Hypertension
Images retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileRenal_FMD2jpg and httpcommonswikimediaorgwikiFileRenal_FMDjpgCreative Commons License associated httpcreativecommonsorglicensesby20deeden (both images)
CASE 2bull OS is a 64year old Hispanic female in for DM check She has had DM for 15+ years and is currently
taking metformin 1000mg bid Lisinopril 10mg a day atorvastatin 40mg a day Labs today showed the following
bull Hgba1c 86 cmp eGFR 50 lipid WNL proteincr ratio 650mg These results are similar to her last visit
bull Upon further hx-you find that she had a recent eye exam and has mild nonproliferaive retinopathy She does not have neuropathy or other ss
bull What further workup do you need
bull Renal sonogram urine micro iPTH vit D (25 OH) phos uric acid
bull Dx stage
bull G3a A3
bull What further treatment do you need
bull Improve glycemic control Increase Lisinopril to 20mg with a goal of 40mg Avoid NSAIDs or other nephrotoxic agents make sure meds are renally dosed monitor 3xyear nephro referral
MANAGEMENT OF CKD IN DIABETESeGFR Recommended
All patients
Yearly measurement of creatinine urinary albumin excretion potassium
45-60 Referral to a nephrologist if possibility for nondiabetickidney disease existsConsider dose adjustment of medicationsMonitor eGFR every 6 monthsMonitor electrolytes bicarbonate hemoglobin calcium phosphorus parathyroid hormone at least yearly
Assure vitamin D sufficiencyConsider bone density testingReferral for dietary counselling
American Diabetes Association Standards of Medical Care in Diabetes Microvascular complications and foot care Diabetes Care 2017 40 (Suppl 1) S88-S98
CASE 3
bull 19 year old African American woman presents to your clinic with complaints of fatigue joint pains a new rash on her face oral ulcer
bull On exam BP 15080 P 88 Afebrile 96 O2 sats on RAbull GEN No respiratory distress at restbull HEENT painless oral ulcer flat rash over malar eminences sparing the nasolabial fold pallor +bull Lungs CTAbull CVS S1S2 regularbull Abdomen soft NTbull Ext left elbow joint and bilateral wrist joints are swollen and tender
bull What would you orderbull CBC CMP ua urine microscopy (microalbumin or urine proteincr ratio) ANA esr RF anti-ccp uric acid TSH
CASE 3
bull Working dx fatigue oral ulcer joint pain
bull Basic Labs Na 135 K 55 Bicarb 18 BUN 50 Cr 35 eGFR 22 Ca 90 ANA + titer 1640
bull UA 3+ blood 3+ protein RBC casts +
bull Given these results what is the most likely diagnosis
bull What would you do
SYSTEMIC LUPUS ERYTHEMATOSUS (SLE)
bull SLE multisystemic disease Etiology unknown
bull Production of autoantibodies and immune complexes formation
bull There is renal involvement in the great majority of patients with SLE at some time of the evolution 66-90
SLE ndash LUPUS NEPHRITIS
bull Race SLE is more commonsevere in African americans than Caucasiansbull
bull Gender female-to-male ratio of 91
bull Age Most patients develop lupus nephritis early in their disease course SLE is more common among women in the third decade of life and lupus nephritis occurs in patients aged 20-40 years
bull Kidney Biopsy For staging lupus nephritis (Class 1-5)
CASE 5bull A 80 year old man who has not seen a PCP in many years
presents to your clinic for weakness for the past few months On further questioning he tells you that his bones also have been hurting lately and he has developed leg swelling in the past month or so
bull On exam bull BP 16090 P 88 Afebrilebull GEN Thin built manbull HEENT pallor presentbull Lungs clearbull CVS S1S2 regular no rub or gallopbull Abdomen soft NTbull Ext 2 + edema
CASE 5
bull Differentials
bull CHF MI Cancer arthritis
bull Labs
bull CBC CMP urine microscopy urine proteincr ratio ESR TSH EKG BNP pa and lat CXR
bull LABS Urine dipstick negative for protein or blood
bull Basic chem bull Na 136 (135-145) K 51 (35-55) Chloride 108 (96-106) Bicarb 25
Given this presentation and the labs (low anion gap and elevated calcium anemia kidney failure) what will you think of What will you order next
Serum and urine protein electrophoresis
Intratubular refractile casts with surrounding syncytial giant cell reaction with chronic tubulointerstitial nephritis and fibrosis characteristic of myeloma cast nephropathy
Kidney Biopsy
CASE STUDYbull A 35 year old African American woman was seen in the clinic for
chronic cough and dyspnea on exertion She gave history of vague symptoms of fatigue and weight loss of 20 Ibs over the last six months
bull List some differentialsbull TB sarcoid lupus thyroid problems PEbull What would you orderbull PPD cbc cmp UA TSH ANA pa and lat cxr
bull Her labs were significant for mildly elevated calcium level and a creatinine of 20 mgdL eGFR 37
bull She had 750 mg of proteinuriaday
bull PPD neg ANA neg TSH and other labs WNL
bull Assuming this is present more than 3 monthshelliphellipwhat is her ckd stage
bull G3b A3
bull What do we still need
CT scan of chest
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileAnterior_mediastinal_mass_thymomajpgCreative Commons License associated httpcreativecommonsorglicensesby20deeden
CXR ndash HILAR LYMPHADENOPATHY
WHATS NEEDED NEXT
bull Biopsy of hilar lymphadenopathy or renal biopsy
bull DX sarcoidosis
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileSarcoidosis_signs_and_symptomsjpgThis work is in the public domain in the United States because it is a work of the United States Federal Government under the terms of Title 17 Chapter 1 Section 105 of the US Code
NEWLY DX CKD
bull 1) urinalysis microscopy ultrasound proteincr ratio
bull If obstruction-treat
bull No obstruction
bull Hx critical (consider myeloma if high risk)
bull glomerular bleeding or albumin in urine
bull Yes workup for glomerular causes (ANArf hep B C upep spep ANCA complement C3 C4)
bull No sterile pyruria-consider interstitial nephritis
bull High risk renovascular disease Evaluate renovascular disease
Additional Online Resources for CKD LearningbullNational Kidney Foundation wwwkidneyorgbullUnited States Renal Data Service wwwusrdsorgbullCDCrsquos CKD Surveillance Project
httpnccdcdcgovckdbullNational Kidney Disease Education Program
(NKDEP) httpnkdepnihgov
BIBLIOGRAPHY
bull Afzali B amp Goldsmith D J (2016 June 29) Statins and chronic kidney disease (G C Curhan amp A M Sheridan Eds) Retrieved 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsstatins-and-chronic-kidney-disease
bull American Diabetes Association Standards of Medical Care in Diabetes (2017) Microvascular complications and foot care Diabetes Care 2017 (40) S88-S98
bull American Diabetes Association Standards of Medical Care in Diabetes (2017) Microvascular complications and foot care Diabetes Care 40 (suppl 1) S88-S98
bull Berns J S (2017 Mar 22) Treatment of anemia in nondialysis chronic kidney disease (T A Golper amp A M Sheridan Eds) Retrieved from UpToDate httpswww-uptodate-comproxywichitaeducontentstreatment-of-anemia-in-nondialysis-chronic-kidney-disease
bull Chan M Dall A T Fletcher K E Lu N amp Trivedi H (2007) Outcomes in patients with chronic kidney disease referred late to nephrologists a meta-analysis American Journal of Medicine 120(12) 1063-1070
bull Coresh J Selvin E amp Stevens L A (2007) Prevalence of chronic kidny disease in the United States JAMA 298(17) doi101001jama298172038
bull de Brito-Ashurst I Varagunam M Raftery M amp Yagoob M (2009) Bicarbonate supplementation slows progression of CKD and improves nutritional status Journal of American Society of Nephrology (20) 2075-2084
BIBLIOGRAPHY
bull Duncan L Heathcoat J Djurdjev O amp Levin A (2001) Screening for renal disease using serum creatinine who are we missing Nephrology Dialysis and Transplant 16(5) 1042-1046
bull Dunkler D Gao P Lee S F Heinz G Clase C M Tobe S Oberbauer R (2015 August 7) Risk prediction for early CKD in type 2 diabetes Retrieved from Clinical Journal of the American Society of Nephrology httpcjasnasnjournalsorgcontent1081371fullsid=61422554-a5f1-41ac-b696-dcd3b12bd268
bull Fatehi P amp Chi-yuan H (September 15 2016) Diagnostic approach to the patient with newly identified chronic kidney disease (G C Curhan amp A M Sheridan Eds) Retrieved May 7 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsdiagnostic-approach-to-the-patient-with-newly-identified-chronic-kidney-disease
bull Fink J e (2009) Chronic Kidney Disease as an Under-Recognized Threat to Patient Safety American journal of kidney diseases the official journal of the National Kidney Foundation 53(4) 681-688
bull Gaffo A L amp Saag K G (2008 Nov) Management of hyperuricemia and gout in CKD doihttpdxdoiorg101053jajkd200807035
bull Hebert L A amp Parikh S V (2014 June 18) Differential diagnosis and evaluation of glomerular disease (R J Glassock amp A Q Lam Eds) Retrieved May 7 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsdifferential-diagnosis-and-evaluation-of-glomerular-disease
bull Inker L Perrone R D Sterns R H amp Forman J P (2017 March 7) Assessment of kidney function Retrieved from UpToDate httpswww-uptodate-comproxywichitaeducontentsassessment-of-kidney-functionsource=search_resultampsearch=creatinineampselectedTitle=1~150
BIBLIOGRAPHY
bull James P A Ortiz E amp Et Al (2014) Evidence based guideline for the management of high blood pressure in adults (JNC) JAMA 311(5) 507-520
bull Kidney Disease Improving Global Outcomes (KDIGO) CKD Work Group (2013 January) KDIGO 2012 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease Retrieved from Kidney International Supplement httpwwwkidney-internationalorg
bull Kunz R Friedrich C Wolbers M amp Mann J F (2008) Meta-analysis effect of monotherapy and combination therapy with inhibitors of the renin angiotensin system on proteinuria in renal disease Annals of Internal Medicine 148(1) 30-48
bull Levey A Stevens L A Schmid C H Castro A F Feldman H I Kusek J W Coresh J (2009) A new equation to estimate glomerular filtration rate Annals of Internal Medicine 150(9) 604-612
bull Levin A Bakris G L Molitch M Smulders M M Williams L A amp Andress D L (2007 Jan) Prevalence of abnormal serum vitamin D PTH calcium and phosphorus in patients with chronic kidney disease results of the study to evaluate early kidney disease Kidney International 71(1) 31-38 Retrieved from PubMED
bull Mahajan A Simoni J Sheather S Broglio K Rajab M amp Wesson D (2010) Daily oral sodium bicarbonate preserves glomerular filtration rate by slowing its decline in early hypertensive nephropathy Kidney International (78_ 303-309
bull Mann J Schmieder R E amp McQueen M (2008) Renal outcomes with telmisartan ramipril or both in people at high vascular risk (the ONTARGET study) a multicentre randomised doubleblind ocntrolled trial Lancet 372(9638) 547-533
BIBLIOGRAPHY
bull Matovinović M S (2009) Pathophysiology and classification of kidney disease Retrieved from The Journal of the International Federation of Clinical Chemistry and Laboratory Medicine httpwwwifccorgifccfilesdocs20010902pdf
bull Moe S Drueke T Lameire N amp Eknoyan G (2007 Jan) Chronic kidney disease-mineral-bone disorder a new paradigmdoi101053jackd200610005
bull Murtagh F E Marsh J E Donohoe P Ekbal N J Sheerin N S amp Harris F E (2007 July) Dialysis or not A comparative survival study of patients over 75 years with chronic kidney disease stage 5 Retrieved from Nephrology Dialysis and Transplant 22(7) httpswwwncbinlmnihgovpubmed17412702
bull National Kidney Foundation (2002) KDOQI clinical practice guidelines for chronic kidney disease evaluation classification andstratification American Journal of Kidney Disease S1-S266
bull National Kidney Foundation (2014 November 5) Fact Sheets Retrieved from httpwwwkidneyorgnewsnewsroomfactsheetsFastFacts
bull Pal S (2012 June 2) Trends in chronic kidney disease Retrieved from US Pharmacist (37)6 httpswwwuspharmacistcomarticletrends-in-chronic-kidney-disease
bull Qunibi W amp Henrich W L (2017 Jan 19) Overview of chronic kidney disease-mineral and bone disorder (J Berns amp A M Sheridan Eds) Retrieved from UpToDate httpswww-uptodate-comoverview-of-chronic-kidney-disease-mineral-and-bone-disorder-ckd-mbd
bull Rosenberg M (2016 Feb 24) Overview of the management of chronic kidney disease in adults (G C Curhan amp A M Sheridan Eds) Retrieved from UpToDate UpToDate httpswww-uptodate-comproxywichitaeducontentsoverview-of-the-management-of-chronic-kidney-disease-in-adults
BIBLIOGRAPHY
bull Szczech L Stewart R C Hsu-Lin S DeLosky R J Astor B C Fox C H Vassalotti J A (2014) Primary care detection of chronic kidney disease in adults with type 2 diabetes The ADD-CKD Study (Awareness Detection and Drug Therapy in type 2 diabetes and chronic kidney disease PLOS doihttpsdoiorg101371journalpone0110535
bull USRDS (2016) Annual data report 2016 Epidemiology of kidney disease in the United States Retrieved from United States Renal Data System httpswwwusrdsorgadraspx
bull Vasudev B amp Vasudev M (2012) A model curriculum for residents rotating in nephrology MedEDPORTAL doihttpdoiorg1015766mep_2374-82658288
bull Wei L MacDonald T M Jennings C Sheng X amp Flynn R W (2013) Estimated GFR reporting is associated with decreased nonsteroidal anti-inflammatory drug prescribing and increased renal function Kidney International (84)1 174-178
chronic kidney disease in primary care
CKD as a Public Health Issue
Slide Number 3
Costs of CKD in 2013 dollarsUSRDS report
Steps to CKD Patient Care
Renal anatomy and physiology
Definition of Chronic Kidney Disease
CKD Risk Factors
Gaps in CKD Diagnosis
Slide Number 10
Steps to CKD Patient Care
creatinine
Glomerular filtration rate
Slide Number 14
Slide Number 15
Use These Equations Cautiously if at all in hellip
lab albumin creatinine ratio
The New CKD Categories
Steps to CKD Patient Care
Slide Number 20
Kidney Involvement in Systemic Diseases
Slide Number 22
Slide Number 23
DysmorphicRenal Hematuria
Slide Number 25
If you have albuminuria or hematuria-order the following labs
Prevalence of Abnormalities of Mineral Metabolism PTH in CKD
Managing CKD-MBD complications
CKD-MBD Testing
Anemia Becomes More Common as Kidney Function Declines
Detect and Manage CKD Complications
Complications-metabolic acidosis
Complications-vascular calcification
Hyperkalemia management
Hyperuricemia levels amp CKD
CKD monitoring levels 345
Slide Number 59
When to Refer to a Nephrologist
When to Refer
Steps to CKD Patient Care
Kidney transplantation
Starting Dialysis in the ElderlyhellipOr Not
Ckd management
Case 1
Slide Number 67
Lab results
Slide Number 69
Hypertensive nephropathy with proteinuria
Slide Number 71
Case 2
Slide Number 73
Management of CKD in Diabetes
Case 3
Case 3
Systemic Lupus Erythematosus (SLE)
SLE ndash Lupus Nephritis
Case 5
Case 5
Slide Number 81
Slide Number 82
Case study
Slide Number 84
CXR ndash Hilar Lymphadenopathy
Whats needed next
Slide Number 87
newly dx ckd
Slide Number 89
Bibliography
bibliography
bibliography
bibliography
bibliography
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileMain_complications_of_persistent_high_blood_pressurepngCreative Commons License associated httpcreativecommonsorglicensesby-sa30
bull 3 months Howevermdashwe have evidence of structural abnormalities Could potentially stage at G3b A3 (red on the heat map)
bull Goal blood pressure
bull JNC 8 14090 NKF 13080
bull Additional lab needed for progression monitoring
bull Cbc renal panel phos Vit D iPTH uric acid urine micro (we already have the renal sono and urine proteincr ratio and lipid)
Selective renal angiography (left lower renal artery) after successful percutaneous balloon dilatation of the stenotic lesionFibromuscular dysplasia in an accessory renal artery causing renovascular hypertension
Secondary Hypertension
Images retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileRenal_FMD2jpg and httpcommonswikimediaorgwikiFileRenal_FMDjpgCreative Commons License associated httpcreativecommonsorglicensesby20deeden (both images)
CASE 2bull OS is a 64year old Hispanic female in for DM check She has had DM for 15+ years and is currently
taking metformin 1000mg bid Lisinopril 10mg a day atorvastatin 40mg a day Labs today showed the following
bull Hgba1c 86 cmp eGFR 50 lipid WNL proteincr ratio 650mg These results are similar to her last visit
bull Upon further hx-you find that she had a recent eye exam and has mild nonproliferaive retinopathy She does not have neuropathy or other ss
bull What further workup do you need
bull Renal sonogram urine micro iPTH vit D (25 OH) phos uric acid
bull Dx stage
bull G3a A3
bull What further treatment do you need
bull Improve glycemic control Increase Lisinopril to 20mg with a goal of 40mg Avoid NSAIDs or other nephrotoxic agents make sure meds are renally dosed monitor 3xyear nephro referral
MANAGEMENT OF CKD IN DIABETESeGFR Recommended
All patients
Yearly measurement of creatinine urinary albumin excretion potassium
45-60 Referral to a nephrologist if possibility for nondiabetickidney disease existsConsider dose adjustment of medicationsMonitor eGFR every 6 monthsMonitor electrolytes bicarbonate hemoglobin calcium phosphorus parathyroid hormone at least yearly
Assure vitamin D sufficiencyConsider bone density testingReferral for dietary counselling
American Diabetes Association Standards of Medical Care in Diabetes Microvascular complications and foot care Diabetes Care 2017 40 (Suppl 1) S88-S98
CASE 3
bull 19 year old African American woman presents to your clinic with complaints of fatigue joint pains a new rash on her face oral ulcer
bull On exam BP 15080 P 88 Afebrile 96 O2 sats on RAbull GEN No respiratory distress at restbull HEENT painless oral ulcer flat rash over malar eminences sparing the nasolabial fold pallor +bull Lungs CTAbull CVS S1S2 regularbull Abdomen soft NTbull Ext left elbow joint and bilateral wrist joints are swollen and tender
bull What would you orderbull CBC CMP ua urine microscopy (microalbumin or urine proteincr ratio) ANA esr RF anti-ccp uric acid TSH
CASE 3
bull Working dx fatigue oral ulcer joint pain
bull Basic Labs Na 135 K 55 Bicarb 18 BUN 50 Cr 35 eGFR 22 Ca 90 ANA + titer 1640
bull UA 3+ blood 3+ protein RBC casts +
bull Given these results what is the most likely diagnosis
bull What would you do
SYSTEMIC LUPUS ERYTHEMATOSUS (SLE)
bull SLE multisystemic disease Etiology unknown
bull Production of autoantibodies and immune complexes formation
bull There is renal involvement in the great majority of patients with SLE at some time of the evolution 66-90
SLE ndash LUPUS NEPHRITIS
bull Race SLE is more commonsevere in African americans than Caucasiansbull
bull Gender female-to-male ratio of 91
bull Age Most patients develop lupus nephritis early in their disease course SLE is more common among women in the third decade of life and lupus nephritis occurs in patients aged 20-40 years
bull Kidney Biopsy For staging lupus nephritis (Class 1-5)
CASE 5bull A 80 year old man who has not seen a PCP in many years
presents to your clinic for weakness for the past few months On further questioning he tells you that his bones also have been hurting lately and he has developed leg swelling in the past month or so
bull On exam bull BP 16090 P 88 Afebrilebull GEN Thin built manbull HEENT pallor presentbull Lungs clearbull CVS S1S2 regular no rub or gallopbull Abdomen soft NTbull Ext 2 + edema
CASE 5
bull Differentials
bull CHF MI Cancer arthritis
bull Labs
bull CBC CMP urine microscopy urine proteincr ratio ESR TSH EKG BNP pa and lat CXR
bull LABS Urine dipstick negative for protein or blood
bull Basic chem bull Na 136 (135-145) K 51 (35-55) Chloride 108 (96-106) Bicarb 25
Given this presentation and the labs (low anion gap and elevated calcium anemia kidney failure) what will you think of What will you order next
Serum and urine protein electrophoresis
Intratubular refractile casts with surrounding syncytial giant cell reaction with chronic tubulointerstitial nephritis and fibrosis characteristic of myeloma cast nephropathy
Kidney Biopsy
CASE STUDYbull A 35 year old African American woman was seen in the clinic for
chronic cough and dyspnea on exertion She gave history of vague symptoms of fatigue and weight loss of 20 Ibs over the last six months
bull List some differentialsbull TB sarcoid lupus thyroid problems PEbull What would you orderbull PPD cbc cmp UA TSH ANA pa and lat cxr
bull Her labs were significant for mildly elevated calcium level and a creatinine of 20 mgdL eGFR 37
bull She had 750 mg of proteinuriaday
bull PPD neg ANA neg TSH and other labs WNL
bull Assuming this is present more than 3 monthshelliphellipwhat is her ckd stage
bull G3b A3
bull What do we still need
CT scan of chest
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileAnterior_mediastinal_mass_thymomajpgCreative Commons License associated httpcreativecommonsorglicensesby20deeden
CXR ndash HILAR LYMPHADENOPATHY
WHATS NEEDED NEXT
bull Biopsy of hilar lymphadenopathy or renal biopsy
bull DX sarcoidosis
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileSarcoidosis_signs_and_symptomsjpgThis work is in the public domain in the United States because it is a work of the United States Federal Government under the terms of Title 17 Chapter 1 Section 105 of the US Code
NEWLY DX CKD
bull 1) urinalysis microscopy ultrasound proteincr ratio
bull If obstruction-treat
bull No obstruction
bull Hx critical (consider myeloma if high risk)
bull glomerular bleeding or albumin in urine
bull Yes workup for glomerular causes (ANArf hep B C upep spep ANCA complement C3 C4)
bull No sterile pyruria-consider interstitial nephritis
bull High risk renovascular disease Evaluate renovascular disease
Additional Online Resources for CKD LearningbullNational Kidney Foundation wwwkidneyorgbullUnited States Renal Data Service wwwusrdsorgbullCDCrsquos CKD Surveillance Project
httpnccdcdcgovckdbullNational Kidney Disease Education Program
(NKDEP) httpnkdepnihgov
BIBLIOGRAPHY
bull Afzali B amp Goldsmith D J (2016 June 29) Statins and chronic kidney disease (G C Curhan amp A M Sheridan Eds) Retrieved 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsstatins-and-chronic-kidney-disease
bull American Diabetes Association Standards of Medical Care in Diabetes (2017) Microvascular complications and foot care Diabetes Care 2017 (40) S88-S98
bull American Diabetes Association Standards of Medical Care in Diabetes (2017) Microvascular complications and foot care Diabetes Care 40 (suppl 1) S88-S98
bull Berns J S (2017 Mar 22) Treatment of anemia in nondialysis chronic kidney disease (T A Golper amp A M Sheridan Eds) Retrieved from UpToDate httpswww-uptodate-comproxywichitaeducontentstreatment-of-anemia-in-nondialysis-chronic-kidney-disease
bull Chan M Dall A T Fletcher K E Lu N amp Trivedi H (2007) Outcomes in patients with chronic kidney disease referred late to nephrologists a meta-analysis American Journal of Medicine 120(12) 1063-1070
bull Coresh J Selvin E amp Stevens L A (2007) Prevalence of chronic kidny disease in the United States JAMA 298(17) doi101001jama298172038
bull de Brito-Ashurst I Varagunam M Raftery M amp Yagoob M (2009) Bicarbonate supplementation slows progression of CKD and improves nutritional status Journal of American Society of Nephrology (20) 2075-2084
BIBLIOGRAPHY
bull Duncan L Heathcoat J Djurdjev O amp Levin A (2001) Screening for renal disease using serum creatinine who are we missing Nephrology Dialysis and Transplant 16(5) 1042-1046
bull Dunkler D Gao P Lee S F Heinz G Clase C M Tobe S Oberbauer R (2015 August 7) Risk prediction for early CKD in type 2 diabetes Retrieved from Clinical Journal of the American Society of Nephrology httpcjasnasnjournalsorgcontent1081371fullsid=61422554-a5f1-41ac-b696-dcd3b12bd268
bull Fatehi P amp Chi-yuan H (September 15 2016) Diagnostic approach to the patient with newly identified chronic kidney disease (G C Curhan amp A M Sheridan Eds) Retrieved May 7 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsdiagnostic-approach-to-the-patient-with-newly-identified-chronic-kidney-disease
bull Fink J e (2009) Chronic Kidney Disease as an Under-Recognized Threat to Patient Safety American journal of kidney diseases the official journal of the National Kidney Foundation 53(4) 681-688
bull Gaffo A L amp Saag K G (2008 Nov) Management of hyperuricemia and gout in CKD doihttpdxdoiorg101053jajkd200807035
bull Hebert L A amp Parikh S V (2014 June 18) Differential diagnosis and evaluation of glomerular disease (R J Glassock amp A Q Lam Eds) Retrieved May 7 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsdifferential-diagnosis-and-evaluation-of-glomerular-disease
bull Inker L Perrone R D Sterns R H amp Forman J P (2017 March 7) Assessment of kidney function Retrieved from UpToDate httpswww-uptodate-comproxywichitaeducontentsassessment-of-kidney-functionsource=search_resultampsearch=creatinineampselectedTitle=1~150
BIBLIOGRAPHY
bull James P A Ortiz E amp Et Al (2014) Evidence based guideline for the management of high blood pressure in adults (JNC) JAMA 311(5) 507-520
bull Kidney Disease Improving Global Outcomes (KDIGO) CKD Work Group (2013 January) KDIGO 2012 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease Retrieved from Kidney International Supplement httpwwwkidney-internationalorg
bull Kunz R Friedrich C Wolbers M amp Mann J F (2008) Meta-analysis effect of monotherapy and combination therapy with inhibitors of the renin angiotensin system on proteinuria in renal disease Annals of Internal Medicine 148(1) 30-48
bull Levey A Stevens L A Schmid C H Castro A F Feldman H I Kusek J W Coresh J (2009) A new equation to estimate glomerular filtration rate Annals of Internal Medicine 150(9) 604-612
bull Levin A Bakris G L Molitch M Smulders M M Williams L A amp Andress D L (2007 Jan) Prevalence of abnormal serum vitamin D PTH calcium and phosphorus in patients with chronic kidney disease results of the study to evaluate early kidney disease Kidney International 71(1) 31-38 Retrieved from PubMED
bull Mahajan A Simoni J Sheather S Broglio K Rajab M amp Wesson D (2010) Daily oral sodium bicarbonate preserves glomerular filtration rate by slowing its decline in early hypertensive nephropathy Kidney International (78_ 303-309
bull Mann J Schmieder R E amp McQueen M (2008) Renal outcomes with telmisartan ramipril or both in people at high vascular risk (the ONTARGET study) a multicentre randomised doubleblind ocntrolled trial Lancet 372(9638) 547-533
BIBLIOGRAPHY
bull Matovinović M S (2009) Pathophysiology and classification of kidney disease Retrieved from The Journal of the International Federation of Clinical Chemistry and Laboratory Medicine httpwwwifccorgifccfilesdocs20010902pdf
bull Moe S Drueke T Lameire N amp Eknoyan G (2007 Jan) Chronic kidney disease-mineral-bone disorder a new paradigmdoi101053jackd200610005
bull Murtagh F E Marsh J E Donohoe P Ekbal N J Sheerin N S amp Harris F E (2007 July) Dialysis or not A comparative survival study of patients over 75 years with chronic kidney disease stage 5 Retrieved from Nephrology Dialysis and Transplant 22(7) httpswwwncbinlmnihgovpubmed17412702
bull National Kidney Foundation (2002) KDOQI clinical practice guidelines for chronic kidney disease evaluation classification andstratification American Journal of Kidney Disease S1-S266
bull National Kidney Foundation (2014 November 5) Fact Sheets Retrieved from httpwwwkidneyorgnewsnewsroomfactsheetsFastFacts
bull Pal S (2012 June 2) Trends in chronic kidney disease Retrieved from US Pharmacist (37)6 httpswwwuspharmacistcomarticletrends-in-chronic-kidney-disease
bull Qunibi W amp Henrich W L (2017 Jan 19) Overview of chronic kidney disease-mineral and bone disorder (J Berns amp A M Sheridan Eds) Retrieved from UpToDate httpswww-uptodate-comoverview-of-chronic-kidney-disease-mineral-and-bone-disorder-ckd-mbd
bull Rosenberg M (2016 Feb 24) Overview of the management of chronic kidney disease in adults (G C Curhan amp A M Sheridan Eds) Retrieved from UpToDate UpToDate httpswww-uptodate-comproxywichitaeducontentsoverview-of-the-management-of-chronic-kidney-disease-in-adults
BIBLIOGRAPHY
bull Szczech L Stewart R C Hsu-Lin S DeLosky R J Astor B C Fox C H Vassalotti J A (2014) Primary care detection of chronic kidney disease in adults with type 2 diabetes The ADD-CKD Study (Awareness Detection and Drug Therapy in type 2 diabetes and chronic kidney disease PLOS doihttpsdoiorg101371journalpone0110535
bull USRDS (2016) Annual data report 2016 Epidemiology of kidney disease in the United States Retrieved from United States Renal Data System httpswwwusrdsorgadraspx
bull Vasudev B amp Vasudev M (2012) A model curriculum for residents rotating in nephrology MedEDPORTAL doihttpdoiorg1015766mep_2374-82658288
bull Wei L MacDonald T M Jennings C Sheng X amp Flynn R W (2013) Estimated GFR reporting is associated with decreased nonsteroidal anti-inflammatory drug prescribing and increased renal function Kidney International (84)1 174-178
chronic kidney disease in primary care
CKD as a Public Health Issue
Slide Number 3
Costs of CKD in 2013 dollarsUSRDS report
Steps to CKD Patient Care
Renal anatomy and physiology
Definition of Chronic Kidney Disease
CKD Risk Factors
Gaps in CKD Diagnosis
Slide Number 10
Steps to CKD Patient Care
creatinine
Glomerular filtration rate
Slide Number 14
Slide Number 15
Use These Equations Cautiously if at all in hellip
lab albumin creatinine ratio
The New CKD Categories
Steps to CKD Patient Care
Slide Number 20
Kidney Involvement in Systemic Diseases
Slide Number 22
Slide Number 23
DysmorphicRenal Hematuria
Slide Number 25
If you have albuminuria or hematuria-order the following labs
bull 3 months Howevermdashwe have evidence of structural abnormalities Could potentially stage at G3b A3 (red on the heat map)
bull Goal blood pressure
bull JNC 8 14090 NKF 13080
bull Additional lab needed for progression monitoring
bull Cbc renal panel phos Vit D iPTH uric acid urine micro (we already have the renal sono and urine proteincr ratio and lipid)
Selective renal angiography (left lower renal artery) after successful percutaneous balloon dilatation of the stenotic lesionFibromuscular dysplasia in an accessory renal artery causing renovascular hypertension
Secondary Hypertension
Images retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileRenal_FMD2jpg and httpcommonswikimediaorgwikiFileRenal_FMDjpgCreative Commons License associated httpcreativecommonsorglicensesby20deeden (both images)
CASE 2bull OS is a 64year old Hispanic female in for DM check She has had DM for 15+ years and is currently
taking metformin 1000mg bid Lisinopril 10mg a day atorvastatin 40mg a day Labs today showed the following
bull Hgba1c 86 cmp eGFR 50 lipid WNL proteincr ratio 650mg These results are similar to her last visit
bull Upon further hx-you find that she had a recent eye exam and has mild nonproliferaive retinopathy She does not have neuropathy or other ss
bull What further workup do you need
bull Renal sonogram urine micro iPTH vit D (25 OH) phos uric acid
bull Dx stage
bull G3a A3
bull What further treatment do you need
bull Improve glycemic control Increase Lisinopril to 20mg with a goal of 40mg Avoid NSAIDs or other nephrotoxic agents make sure meds are renally dosed monitor 3xyear nephro referral
MANAGEMENT OF CKD IN DIABETESeGFR Recommended
All patients
Yearly measurement of creatinine urinary albumin excretion potassium
45-60 Referral to a nephrologist if possibility for nondiabetickidney disease existsConsider dose adjustment of medicationsMonitor eGFR every 6 monthsMonitor electrolytes bicarbonate hemoglobin calcium phosphorus parathyroid hormone at least yearly
Assure vitamin D sufficiencyConsider bone density testingReferral for dietary counselling
American Diabetes Association Standards of Medical Care in Diabetes Microvascular complications and foot care Diabetes Care 2017 40 (Suppl 1) S88-S98
CASE 3
bull 19 year old African American woman presents to your clinic with complaints of fatigue joint pains a new rash on her face oral ulcer
bull On exam BP 15080 P 88 Afebrile 96 O2 sats on RAbull GEN No respiratory distress at restbull HEENT painless oral ulcer flat rash over malar eminences sparing the nasolabial fold pallor +bull Lungs CTAbull CVS S1S2 regularbull Abdomen soft NTbull Ext left elbow joint and bilateral wrist joints are swollen and tender
bull What would you orderbull CBC CMP ua urine microscopy (microalbumin or urine proteincr ratio) ANA esr RF anti-ccp uric acid TSH
CASE 3
bull Working dx fatigue oral ulcer joint pain
bull Basic Labs Na 135 K 55 Bicarb 18 BUN 50 Cr 35 eGFR 22 Ca 90 ANA + titer 1640
bull UA 3+ blood 3+ protein RBC casts +
bull Given these results what is the most likely diagnosis
bull What would you do
SYSTEMIC LUPUS ERYTHEMATOSUS (SLE)
bull SLE multisystemic disease Etiology unknown
bull Production of autoantibodies and immune complexes formation
bull There is renal involvement in the great majority of patients with SLE at some time of the evolution 66-90
SLE ndash LUPUS NEPHRITIS
bull Race SLE is more commonsevere in African americans than Caucasiansbull
bull Gender female-to-male ratio of 91
bull Age Most patients develop lupus nephritis early in their disease course SLE is more common among women in the third decade of life and lupus nephritis occurs in patients aged 20-40 years
bull Kidney Biopsy For staging lupus nephritis (Class 1-5)
CASE 5bull A 80 year old man who has not seen a PCP in many years
presents to your clinic for weakness for the past few months On further questioning he tells you that his bones also have been hurting lately and he has developed leg swelling in the past month or so
bull On exam bull BP 16090 P 88 Afebrilebull GEN Thin built manbull HEENT pallor presentbull Lungs clearbull CVS S1S2 regular no rub or gallopbull Abdomen soft NTbull Ext 2 + edema
CASE 5
bull Differentials
bull CHF MI Cancer arthritis
bull Labs
bull CBC CMP urine microscopy urine proteincr ratio ESR TSH EKG BNP pa and lat CXR
bull LABS Urine dipstick negative for protein or blood
bull Basic chem bull Na 136 (135-145) K 51 (35-55) Chloride 108 (96-106) Bicarb 25
Given this presentation and the labs (low anion gap and elevated calcium anemia kidney failure) what will you think of What will you order next
Serum and urine protein electrophoresis
Intratubular refractile casts with surrounding syncytial giant cell reaction with chronic tubulointerstitial nephritis and fibrosis characteristic of myeloma cast nephropathy
Kidney Biopsy
CASE STUDYbull A 35 year old African American woman was seen in the clinic for
chronic cough and dyspnea on exertion She gave history of vague symptoms of fatigue and weight loss of 20 Ibs over the last six months
bull List some differentialsbull TB sarcoid lupus thyroid problems PEbull What would you orderbull PPD cbc cmp UA TSH ANA pa and lat cxr
bull Her labs were significant for mildly elevated calcium level and a creatinine of 20 mgdL eGFR 37
bull She had 750 mg of proteinuriaday
bull PPD neg ANA neg TSH and other labs WNL
bull Assuming this is present more than 3 monthshelliphellipwhat is her ckd stage
bull G3b A3
bull What do we still need
CT scan of chest
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileAnterior_mediastinal_mass_thymomajpgCreative Commons License associated httpcreativecommonsorglicensesby20deeden
CXR ndash HILAR LYMPHADENOPATHY
WHATS NEEDED NEXT
bull Biopsy of hilar lymphadenopathy or renal biopsy
bull DX sarcoidosis
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileSarcoidosis_signs_and_symptomsjpgThis work is in the public domain in the United States because it is a work of the United States Federal Government under the terms of Title 17 Chapter 1 Section 105 of the US Code
NEWLY DX CKD
bull 1) urinalysis microscopy ultrasound proteincr ratio
bull If obstruction-treat
bull No obstruction
bull Hx critical (consider myeloma if high risk)
bull glomerular bleeding or albumin in urine
bull Yes workup for glomerular causes (ANArf hep B C upep spep ANCA complement C3 C4)
bull No sterile pyruria-consider interstitial nephritis
bull High risk renovascular disease Evaluate renovascular disease
Additional Online Resources for CKD LearningbullNational Kidney Foundation wwwkidneyorgbullUnited States Renal Data Service wwwusrdsorgbullCDCrsquos CKD Surveillance Project
httpnccdcdcgovckdbullNational Kidney Disease Education Program
(NKDEP) httpnkdepnihgov
BIBLIOGRAPHY
bull Afzali B amp Goldsmith D J (2016 June 29) Statins and chronic kidney disease (G C Curhan amp A M Sheridan Eds) Retrieved 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsstatins-and-chronic-kidney-disease
bull American Diabetes Association Standards of Medical Care in Diabetes (2017) Microvascular complications and foot care Diabetes Care 2017 (40) S88-S98
bull American Diabetes Association Standards of Medical Care in Diabetes (2017) Microvascular complications and foot care Diabetes Care 40 (suppl 1) S88-S98
bull Berns J S (2017 Mar 22) Treatment of anemia in nondialysis chronic kidney disease (T A Golper amp A M Sheridan Eds) Retrieved from UpToDate httpswww-uptodate-comproxywichitaeducontentstreatment-of-anemia-in-nondialysis-chronic-kidney-disease
bull Chan M Dall A T Fletcher K E Lu N amp Trivedi H (2007) Outcomes in patients with chronic kidney disease referred late to nephrologists a meta-analysis American Journal of Medicine 120(12) 1063-1070
bull Coresh J Selvin E amp Stevens L A (2007) Prevalence of chronic kidny disease in the United States JAMA 298(17) doi101001jama298172038
bull de Brito-Ashurst I Varagunam M Raftery M amp Yagoob M (2009) Bicarbonate supplementation slows progression of CKD and improves nutritional status Journal of American Society of Nephrology (20) 2075-2084
BIBLIOGRAPHY
bull Duncan L Heathcoat J Djurdjev O amp Levin A (2001) Screening for renal disease using serum creatinine who are we missing Nephrology Dialysis and Transplant 16(5) 1042-1046
bull Dunkler D Gao P Lee S F Heinz G Clase C M Tobe S Oberbauer R (2015 August 7) Risk prediction for early CKD in type 2 diabetes Retrieved from Clinical Journal of the American Society of Nephrology httpcjasnasnjournalsorgcontent1081371fullsid=61422554-a5f1-41ac-b696-dcd3b12bd268
bull Fatehi P amp Chi-yuan H (September 15 2016) Diagnostic approach to the patient with newly identified chronic kidney disease (G C Curhan amp A M Sheridan Eds) Retrieved May 7 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsdiagnostic-approach-to-the-patient-with-newly-identified-chronic-kidney-disease
bull Fink J e (2009) Chronic Kidney Disease as an Under-Recognized Threat to Patient Safety American journal of kidney diseases the official journal of the National Kidney Foundation 53(4) 681-688
bull Gaffo A L amp Saag K G (2008 Nov) Management of hyperuricemia and gout in CKD doihttpdxdoiorg101053jajkd200807035
bull Hebert L A amp Parikh S V (2014 June 18) Differential diagnosis and evaluation of glomerular disease (R J Glassock amp A Q Lam Eds) Retrieved May 7 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsdifferential-diagnosis-and-evaluation-of-glomerular-disease
bull Inker L Perrone R D Sterns R H amp Forman J P (2017 March 7) Assessment of kidney function Retrieved from UpToDate httpswww-uptodate-comproxywichitaeducontentsassessment-of-kidney-functionsource=search_resultampsearch=creatinineampselectedTitle=1~150
BIBLIOGRAPHY
bull James P A Ortiz E amp Et Al (2014) Evidence based guideline for the management of high blood pressure in adults (JNC) JAMA 311(5) 507-520
bull Kidney Disease Improving Global Outcomes (KDIGO) CKD Work Group (2013 January) KDIGO 2012 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease Retrieved from Kidney International Supplement httpwwwkidney-internationalorg
bull Kunz R Friedrich C Wolbers M amp Mann J F (2008) Meta-analysis effect of monotherapy and combination therapy with inhibitors of the renin angiotensin system on proteinuria in renal disease Annals of Internal Medicine 148(1) 30-48
bull Levey A Stevens L A Schmid C H Castro A F Feldman H I Kusek J W Coresh J (2009) A new equation to estimate glomerular filtration rate Annals of Internal Medicine 150(9) 604-612
bull Levin A Bakris G L Molitch M Smulders M M Williams L A amp Andress D L (2007 Jan) Prevalence of abnormal serum vitamin D PTH calcium and phosphorus in patients with chronic kidney disease results of the study to evaluate early kidney disease Kidney International 71(1) 31-38 Retrieved from PubMED
bull Mahajan A Simoni J Sheather S Broglio K Rajab M amp Wesson D (2010) Daily oral sodium bicarbonate preserves glomerular filtration rate by slowing its decline in early hypertensive nephropathy Kidney International (78_ 303-309
bull Mann J Schmieder R E amp McQueen M (2008) Renal outcomes with telmisartan ramipril or both in people at high vascular risk (the ONTARGET study) a multicentre randomised doubleblind ocntrolled trial Lancet 372(9638) 547-533
BIBLIOGRAPHY
bull Matovinović M S (2009) Pathophysiology and classification of kidney disease Retrieved from The Journal of the International Federation of Clinical Chemistry and Laboratory Medicine httpwwwifccorgifccfilesdocs20010902pdf
bull Moe S Drueke T Lameire N amp Eknoyan G (2007 Jan) Chronic kidney disease-mineral-bone disorder a new paradigmdoi101053jackd200610005
bull Murtagh F E Marsh J E Donohoe P Ekbal N J Sheerin N S amp Harris F E (2007 July) Dialysis or not A comparative survival study of patients over 75 years with chronic kidney disease stage 5 Retrieved from Nephrology Dialysis and Transplant 22(7) httpswwwncbinlmnihgovpubmed17412702
bull National Kidney Foundation (2002) KDOQI clinical practice guidelines for chronic kidney disease evaluation classification andstratification American Journal of Kidney Disease S1-S266
bull National Kidney Foundation (2014 November 5) Fact Sheets Retrieved from httpwwwkidneyorgnewsnewsroomfactsheetsFastFacts
bull Pal S (2012 June 2) Trends in chronic kidney disease Retrieved from US Pharmacist (37)6 httpswwwuspharmacistcomarticletrends-in-chronic-kidney-disease
bull Qunibi W amp Henrich W L (2017 Jan 19) Overview of chronic kidney disease-mineral and bone disorder (J Berns amp A M Sheridan Eds) Retrieved from UpToDate httpswww-uptodate-comoverview-of-chronic-kidney-disease-mineral-and-bone-disorder-ckd-mbd
bull Rosenberg M (2016 Feb 24) Overview of the management of chronic kidney disease in adults (G C Curhan amp A M Sheridan Eds) Retrieved from UpToDate UpToDate httpswww-uptodate-comproxywichitaeducontentsoverview-of-the-management-of-chronic-kidney-disease-in-adults
BIBLIOGRAPHY
bull Szczech L Stewart R C Hsu-Lin S DeLosky R J Astor B C Fox C H Vassalotti J A (2014) Primary care detection of chronic kidney disease in adults with type 2 diabetes The ADD-CKD Study (Awareness Detection and Drug Therapy in type 2 diabetes and chronic kidney disease PLOS doihttpsdoiorg101371journalpone0110535
bull USRDS (2016) Annual data report 2016 Epidemiology of kidney disease in the United States Retrieved from United States Renal Data System httpswwwusrdsorgadraspx
bull Vasudev B amp Vasudev M (2012) A model curriculum for residents rotating in nephrology MedEDPORTAL doihttpdoiorg1015766mep_2374-82658288
bull Wei L MacDonald T M Jennings C Sheng X amp Flynn R W (2013) Estimated GFR reporting is associated with decreased nonsteroidal anti-inflammatory drug prescribing and increased renal function Kidney International (84)1 174-178
chronic kidney disease in primary care
CKD as a Public Health Issue
Slide Number 3
Costs of CKD in 2013 dollarsUSRDS report
Steps to CKD Patient Care
Renal anatomy and physiology
Definition of Chronic Kidney Disease
CKD Risk Factors
Gaps in CKD Diagnosis
Slide Number 10
Steps to CKD Patient Care
creatinine
Glomerular filtration rate
Slide Number 14
Slide Number 15
Use These Equations Cautiously if at all in hellip
lab albumin creatinine ratio
The New CKD Categories
Steps to CKD Patient Care
Slide Number 20
Kidney Involvement in Systemic Diseases
Slide Number 22
Slide Number 23
DysmorphicRenal Hematuria
Slide Number 25
If you have albuminuria or hematuria-order the following labs
Prevalence of Abnormalities of Mineral Metabolism PTH in CKD
Managing CKD-MBD complications
CKD-MBD Testing
Anemia Becomes More Common as Kidney Function Declines
Detect and Manage CKD Complications
Complications-metabolic acidosis
Complications-vascular calcification
Hyperkalemia management
Hyperuricemia levels amp CKD
CKD monitoring levels 345
Slide Number 59
When to Refer to a Nephrologist
When to Refer
Steps to CKD Patient Care
Kidney transplantation
Starting Dialysis in the ElderlyhellipOr Not
Ckd management
Case 1
Slide Number 67
Lab results
Slide Number 69
Hypertensive nephropathy with proteinuria
Slide Number 71
Case 2
Slide Number 73
Management of CKD in Diabetes
Case 3
Case 3
Systemic Lupus Erythematosus (SLE)
SLE ndash Lupus Nephritis
Case 5
Case 5
Slide Number 81
Slide Number 82
Case study
Slide Number 84
CXR ndash Hilar Lymphadenopathy
Whats needed next
Slide Number 87
newly dx ckd
Slide Number 89
Bibliography
bibliography
bibliography
bibliography
bibliography
Selective renal angiography (left lower renal artery) after successful percutaneous balloon dilatation of the stenotic lesionFibromuscular dysplasia in an accessory renal artery causing renovascular hypertension
Secondary Hypertension
Images retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileRenal_FMD2jpg and httpcommonswikimediaorgwikiFileRenal_FMDjpgCreative Commons License associated httpcreativecommonsorglicensesby20deeden (both images)
CASE 2bull OS is a 64year old Hispanic female in for DM check She has had DM for 15+ years and is currently
taking metformin 1000mg bid Lisinopril 10mg a day atorvastatin 40mg a day Labs today showed the following
bull Hgba1c 86 cmp eGFR 50 lipid WNL proteincr ratio 650mg These results are similar to her last visit
bull Upon further hx-you find that she had a recent eye exam and has mild nonproliferaive retinopathy She does not have neuropathy or other ss
bull What further workup do you need
bull Renal sonogram urine micro iPTH vit D (25 OH) phos uric acid
bull Dx stage
bull G3a A3
bull What further treatment do you need
bull Improve glycemic control Increase Lisinopril to 20mg with a goal of 40mg Avoid NSAIDs or other nephrotoxic agents make sure meds are renally dosed monitor 3xyear nephro referral
MANAGEMENT OF CKD IN DIABETESeGFR Recommended
All patients
Yearly measurement of creatinine urinary albumin excretion potassium
45-60 Referral to a nephrologist if possibility for nondiabetickidney disease existsConsider dose adjustment of medicationsMonitor eGFR every 6 monthsMonitor electrolytes bicarbonate hemoglobin calcium phosphorus parathyroid hormone at least yearly
Assure vitamin D sufficiencyConsider bone density testingReferral for dietary counselling
American Diabetes Association Standards of Medical Care in Diabetes Microvascular complications and foot care Diabetes Care 2017 40 (Suppl 1) S88-S98
CASE 3
bull 19 year old African American woman presents to your clinic with complaints of fatigue joint pains a new rash on her face oral ulcer
bull On exam BP 15080 P 88 Afebrile 96 O2 sats on RAbull GEN No respiratory distress at restbull HEENT painless oral ulcer flat rash over malar eminences sparing the nasolabial fold pallor +bull Lungs CTAbull CVS S1S2 regularbull Abdomen soft NTbull Ext left elbow joint and bilateral wrist joints are swollen and tender
bull What would you orderbull CBC CMP ua urine microscopy (microalbumin or urine proteincr ratio) ANA esr RF anti-ccp uric acid TSH
CASE 3
bull Working dx fatigue oral ulcer joint pain
bull Basic Labs Na 135 K 55 Bicarb 18 BUN 50 Cr 35 eGFR 22 Ca 90 ANA + titer 1640
bull UA 3+ blood 3+ protein RBC casts +
bull Given these results what is the most likely diagnosis
bull What would you do
SYSTEMIC LUPUS ERYTHEMATOSUS (SLE)
bull SLE multisystemic disease Etiology unknown
bull Production of autoantibodies and immune complexes formation
bull There is renal involvement in the great majority of patients with SLE at some time of the evolution 66-90
SLE ndash LUPUS NEPHRITIS
bull Race SLE is more commonsevere in African americans than Caucasiansbull
bull Gender female-to-male ratio of 91
bull Age Most patients develop lupus nephritis early in their disease course SLE is more common among women in the third decade of life and lupus nephritis occurs in patients aged 20-40 years
bull Kidney Biopsy For staging lupus nephritis (Class 1-5)
CASE 5bull A 80 year old man who has not seen a PCP in many years
presents to your clinic for weakness for the past few months On further questioning he tells you that his bones also have been hurting lately and he has developed leg swelling in the past month or so
bull On exam bull BP 16090 P 88 Afebrilebull GEN Thin built manbull HEENT pallor presentbull Lungs clearbull CVS S1S2 regular no rub or gallopbull Abdomen soft NTbull Ext 2 + edema
CASE 5
bull Differentials
bull CHF MI Cancer arthritis
bull Labs
bull CBC CMP urine microscopy urine proteincr ratio ESR TSH EKG BNP pa and lat CXR
bull LABS Urine dipstick negative for protein or blood
bull Basic chem bull Na 136 (135-145) K 51 (35-55) Chloride 108 (96-106) Bicarb 25
Given this presentation and the labs (low anion gap and elevated calcium anemia kidney failure) what will you think of What will you order next
Serum and urine protein electrophoresis
Intratubular refractile casts with surrounding syncytial giant cell reaction with chronic tubulointerstitial nephritis and fibrosis characteristic of myeloma cast nephropathy
Kidney Biopsy
CASE STUDYbull A 35 year old African American woman was seen in the clinic for
chronic cough and dyspnea on exertion She gave history of vague symptoms of fatigue and weight loss of 20 Ibs over the last six months
bull List some differentialsbull TB sarcoid lupus thyroid problems PEbull What would you orderbull PPD cbc cmp UA TSH ANA pa and lat cxr
bull Her labs were significant for mildly elevated calcium level and a creatinine of 20 mgdL eGFR 37
bull She had 750 mg of proteinuriaday
bull PPD neg ANA neg TSH and other labs WNL
bull Assuming this is present more than 3 monthshelliphellipwhat is her ckd stage
bull G3b A3
bull What do we still need
CT scan of chest
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileAnterior_mediastinal_mass_thymomajpgCreative Commons License associated httpcreativecommonsorglicensesby20deeden
CXR ndash HILAR LYMPHADENOPATHY
WHATS NEEDED NEXT
bull Biopsy of hilar lymphadenopathy or renal biopsy
bull DX sarcoidosis
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileSarcoidosis_signs_and_symptomsjpgThis work is in the public domain in the United States because it is a work of the United States Federal Government under the terms of Title 17 Chapter 1 Section 105 of the US Code
NEWLY DX CKD
bull 1) urinalysis microscopy ultrasound proteincr ratio
bull If obstruction-treat
bull No obstruction
bull Hx critical (consider myeloma if high risk)
bull glomerular bleeding or albumin in urine
bull Yes workup for glomerular causes (ANArf hep B C upep spep ANCA complement C3 C4)
bull No sterile pyruria-consider interstitial nephritis
bull High risk renovascular disease Evaluate renovascular disease
Additional Online Resources for CKD LearningbullNational Kidney Foundation wwwkidneyorgbullUnited States Renal Data Service wwwusrdsorgbullCDCrsquos CKD Surveillance Project
httpnccdcdcgovckdbullNational Kidney Disease Education Program
(NKDEP) httpnkdepnihgov
BIBLIOGRAPHY
bull Afzali B amp Goldsmith D J (2016 June 29) Statins and chronic kidney disease (G C Curhan amp A M Sheridan Eds) Retrieved 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsstatins-and-chronic-kidney-disease
bull American Diabetes Association Standards of Medical Care in Diabetes (2017) Microvascular complications and foot care Diabetes Care 2017 (40) S88-S98
bull American Diabetes Association Standards of Medical Care in Diabetes (2017) Microvascular complications and foot care Diabetes Care 40 (suppl 1) S88-S98
bull Berns J S (2017 Mar 22) Treatment of anemia in nondialysis chronic kidney disease (T A Golper amp A M Sheridan Eds) Retrieved from UpToDate httpswww-uptodate-comproxywichitaeducontentstreatment-of-anemia-in-nondialysis-chronic-kidney-disease
bull Chan M Dall A T Fletcher K E Lu N amp Trivedi H (2007) Outcomes in patients with chronic kidney disease referred late to nephrologists a meta-analysis American Journal of Medicine 120(12) 1063-1070
bull Coresh J Selvin E amp Stevens L A (2007) Prevalence of chronic kidny disease in the United States JAMA 298(17) doi101001jama298172038
bull de Brito-Ashurst I Varagunam M Raftery M amp Yagoob M (2009) Bicarbonate supplementation slows progression of CKD and improves nutritional status Journal of American Society of Nephrology (20) 2075-2084
BIBLIOGRAPHY
bull Duncan L Heathcoat J Djurdjev O amp Levin A (2001) Screening for renal disease using serum creatinine who are we missing Nephrology Dialysis and Transplant 16(5) 1042-1046
bull Dunkler D Gao P Lee S F Heinz G Clase C M Tobe S Oberbauer R (2015 August 7) Risk prediction for early CKD in type 2 diabetes Retrieved from Clinical Journal of the American Society of Nephrology httpcjasnasnjournalsorgcontent1081371fullsid=61422554-a5f1-41ac-b696-dcd3b12bd268
bull Fatehi P amp Chi-yuan H (September 15 2016) Diagnostic approach to the patient with newly identified chronic kidney disease (G C Curhan amp A M Sheridan Eds) Retrieved May 7 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsdiagnostic-approach-to-the-patient-with-newly-identified-chronic-kidney-disease
bull Fink J e (2009) Chronic Kidney Disease as an Under-Recognized Threat to Patient Safety American journal of kidney diseases the official journal of the National Kidney Foundation 53(4) 681-688
bull Gaffo A L amp Saag K G (2008 Nov) Management of hyperuricemia and gout in CKD doihttpdxdoiorg101053jajkd200807035
bull Hebert L A amp Parikh S V (2014 June 18) Differential diagnosis and evaluation of glomerular disease (R J Glassock amp A Q Lam Eds) Retrieved May 7 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsdifferential-diagnosis-and-evaluation-of-glomerular-disease
bull Inker L Perrone R D Sterns R H amp Forman J P (2017 March 7) Assessment of kidney function Retrieved from UpToDate httpswww-uptodate-comproxywichitaeducontentsassessment-of-kidney-functionsource=search_resultampsearch=creatinineampselectedTitle=1~150
BIBLIOGRAPHY
bull James P A Ortiz E amp Et Al (2014) Evidence based guideline for the management of high blood pressure in adults (JNC) JAMA 311(5) 507-520
bull Kidney Disease Improving Global Outcomes (KDIGO) CKD Work Group (2013 January) KDIGO 2012 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease Retrieved from Kidney International Supplement httpwwwkidney-internationalorg
bull Kunz R Friedrich C Wolbers M amp Mann J F (2008) Meta-analysis effect of monotherapy and combination therapy with inhibitors of the renin angiotensin system on proteinuria in renal disease Annals of Internal Medicine 148(1) 30-48
bull Levey A Stevens L A Schmid C H Castro A F Feldman H I Kusek J W Coresh J (2009) A new equation to estimate glomerular filtration rate Annals of Internal Medicine 150(9) 604-612
bull Levin A Bakris G L Molitch M Smulders M M Williams L A amp Andress D L (2007 Jan) Prevalence of abnormal serum vitamin D PTH calcium and phosphorus in patients with chronic kidney disease results of the study to evaluate early kidney disease Kidney International 71(1) 31-38 Retrieved from PubMED
bull Mahajan A Simoni J Sheather S Broglio K Rajab M amp Wesson D (2010) Daily oral sodium bicarbonate preserves glomerular filtration rate by slowing its decline in early hypertensive nephropathy Kidney International (78_ 303-309
bull Mann J Schmieder R E amp McQueen M (2008) Renal outcomes with telmisartan ramipril or both in people at high vascular risk (the ONTARGET study) a multicentre randomised doubleblind ocntrolled trial Lancet 372(9638) 547-533
BIBLIOGRAPHY
bull Matovinović M S (2009) Pathophysiology and classification of kidney disease Retrieved from The Journal of the International Federation of Clinical Chemistry and Laboratory Medicine httpwwwifccorgifccfilesdocs20010902pdf
bull Moe S Drueke T Lameire N amp Eknoyan G (2007 Jan) Chronic kidney disease-mineral-bone disorder a new paradigmdoi101053jackd200610005
bull Murtagh F E Marsh J E Donohoe P Ekbal N J Sheerin N S amp Harris F E (2007 July) Dialysis or not A comparative survival study of patients over 75 years with chronic kidney disease stage 5 Retrieved from Nephrology Dialysis and Transplant 22(7) httpswwwncbinlmnihgovpubmed17412702
bull National Kidney Foundation (2002) KDOQI clinical practice guidelines for chronic kidney disease evaluation classification andstratification American Journal of Kidney Disease S1-S266
bull National Kidney Foundation (2014 November 5) Fact Sheets Retrieved from httpwwwkidneyorgnewsnewsroomfactsheetsFastFacts
bull Pal S (2012 June 2) Trends in chronic kidney disease Retrieved from US Pharmacist (37)6 httpswwwuspharmacistcomarticletrends-in-chronic-kidney-disease
bull Qunibi W amp Henrich W L (2017 Jan 19) Overview of chronic kidney disease-mineral and bone disorder (J Berns amp A M Sheridan Eds) Retrieved from UpToDate httpswww-uptodate-comoverview-of-chronic-kidney-disease-mineral-and-bone-disorder-ckd-mbd
bull Rosenberg M (2016 Feb 24) Overview of the management of chronic kidney disease in adults (G C Curhan amp A M Sheridan Eds) Retrieved from UpToDate UpToDate httpswww-uptodate-comproxywichitaeducontentsoverview-of-the-management-of-chronic-kidney-disease-in-adults
BIBLIOGRAPHY
bull Szczech L Stewart R C Hsu-Lin S DeLosky R J Astor B C Fox C H Vassalotti J A (2014) Primary care detection of chronic kidney disease in adults with type 2 diabetes The ADD-CKD Study (Awareness Detection and Drug Therapy in type 2 diabetes and chronic kidney disease PLOS doihttpsdoiorg101371journalpone0110535
bull USRDS (2016) Annual data report 2016 Epidemiology of kidney disease in the United States Retrieved from United States Renal Data System httpswwwusrdsorgadraspx
bull Vasudev B amp Vasudev M (2012) A model curriculum for residents rotating in nephrology MedEDPORTAL doihttpdoiorg1015766mep_2374-82658288
bull Wei L MacDonald T M Jennings C Sheng X amp Flynn R W (2013) Estimated GFR reporting is associated with decreased nonsteroidal anti-inflammatory drug prescribing and increased renal function Kidney International (84)1 174-178
chronic kidney disease in primary care
CKD as a Public Health Issue
Slide Number 3
Costs of CKD in 2013 dollarsUSRDS report
Steps to CKD Patient Care
Renal anatomy and physiology
Definition of Chronic Kidney Disease
CKD Risk Factors
Gaps in CKD Diagnosis
Slide Number 10
Steps to CKD Patient Care
creatinine
Glomerular filtration rate
Slide Number 14
Slide Number 15
Use These Equations Cautiously if at all in hellip
lab albumin creatinine ratio
The New CKD Categories
Steps to CKD Patient Care
Slide Number 20
Kidney Involvement in Systemic Diseases
Slide Number 22
Slide Number 23
DysmorphicRenal Hematuria
Slide Number 25
If you have albuminuria or hematuria-order the following labs
Prevalence of Abnormalities of Mineral Metabolism PTH in CKD
Managing CKD-MBD complications
CKD-MBD Testing
Anemia Becomes More Common as Kidney Function Declines
Detect and Manage CKD Complications
Complications-metabolic acidosis
Complications-vascular calcification
Hyperkalemia management
Hyperuricemia levels amp CKD
CKD monitoring levels 345
Slide Number 59
When to Refer to a Nephrologist
When to Refer
Steps to CKD Patient Care
Kidney transplantation
Starting Dialysis in the ElderlyhellipOr Not
Ckd management
Case 1
Slide Number 67
Lab results
Slide Number 69
Hypertensive nephropathy with proteinuria
Slide Number 71
Case 2
Slide Number 73
Management of CKD in Diabetes
Case 3
Case 3
Systemic Lupus Erythematosus (SLE)
SLE ndash Lupus Nephritis
Case 5
Case 5
Slide Number 81
Slide Number 82
Case study
Slide Number 84
CXR ndash Hilar Lymphadenopathy
Whats needed next
Slide Number 87
newly dx ckd
Slide Number 89
Bibliography
bibliography
bibliography
bibliography
bibliography
CASE 2bull OS is a 64year old Hispanic female in for DM check She has had DM for 15+ years and is currently
taking metformin 1000mg bid Lisinopril 10mg a day atorvastatin 40mg a day Labs today showed the following
bull Hgba1c 86 cmp eGFR 50 lipid WNL proteincr ratio 650mg These results are similar to her last visit
bull Upon further hx-you find that she had a recent eye exam and has mild nonproliferaive retinopathy She does not have neuropathy or other ss
bull What further workup do you need
bull Renal sonogram urine micro iPTH vit D (25 OH) phos uric acid
bull Dx stage
bull G3a A3
bull What further treatment do you need
bull Improve glycemic control Increase Lisinopril to 20mg with a goal of 40mg Avoid NSAIDs or other nephrotoxic agents make sure meds are renally dosed monitor 3xyear nephro referral
MANAGEMENT OF CKD IN DIABETESeGFR Recommended
All patients
Yearly measurement of creatinine urinary albumin excretion potassium
45-60 Referral to a nephrologist if possibility for nondiabetickidney disease existsConsider dose adjustment of medicationsMonitor eGFR every 6 monthsMonitor electrolytes bicarbonate hemoglobin calcium phosphorus parathyroid hormone at least yearly
Assure vitamin D sufficiencyConsider bone density testingReferral for dietary counselling
American Diabetes Association Standards of Medical Care in Diabetes Microvascular complications and foot care Diabetes Care 2017 40 (Suppl 1) S88-S98
CASE 3
bull 19 year old African American woman presents to your clinic with complaints of fatigue joint pains a new rash on her face oral ulcer
bull On exam BP 15080 P 88 Afebrile 96 O2 sats on RAbull GEN No respiratory distress at restbull HEENT painless oral ulcer flat rash over malar eminences sparing the nasolabial fold pallor +bull Lungs CTAbull CVS S1S2 regularbull Abdomen soft NTbull Ext left elbow joint and bilateral wrist joints are swollen and tender
bull What would you orderbull CBC CMP ua urine microscopy (microalbumin or urine proteincr ratio) ANA esr RF anti-ccp uric acid TSH
CASE 3
bull Working dx fatigue oral ulcer joint pain
bull Basic Labs Na 135 K 55 Bicarb 18 BUN 50 Cr 35 eGFR 22 Ca 90 ANA + titer 1640
bull UA 3+ blood 3+ protein RBC casts +
bull Given these results what is the most likely diagnosis
bull What would you do
SYSTEMIC LUPUS ERYTHEMATOSUS (SLE)
bull SLE multisystemic disease Etiology unknown
bull Production of autoantibodies and immune complexes formation
bull There is renal involvement in the great majority of patients with SLE at some time of the evolution 66-90
SLE ndash LUPUS NEPHRITIS
bull Race SLE is more commonsevere in African americans than Caucasiansbull
bull Gender female-to-male ratio of 91
bull Age Most patients develop lupus nephritis early in their disease course SLE is more common among women in the third decade of life and lupus nephritis occurs in patients aged 20-40 years
bull Kidney Biopsy For staging lupus nephritis (Class 1-5)
CASE 5bull A 80 year old man who has not seen a PCP in many years
presents to your clinic for weakness for the past few months On further questioning he tells you that his bones also have been hurting lately and he has developed leg swelling in the past month or so
bull On exam bull BP 16090 P 88 Afebrilebull GEN Thin built manbull HEENT pallor presentbull Lungs clearbull CVS S1S2 regular no rub or gallopbull Abdomen soft NTbull Ext 2 + edema
CASE 5
bull Differentials
bull CHF MI Cancer arthritis
bull Labs
bull CBC CMP urine microscopy urine proteincr ratio ESR TSH EKG BNP pa and lat CXR
bull LABS Urine dipstick negative for protein or blood
bull Basic chem bull Na 136 (135-145) K 51 (35-55) Chloride 108 (96-106) Bicarb 25
Given this presentation and the labs (low anion gap and elevated calcium anemia kidney failure) what will you think of What will you order next
Serum and urine protein electrophoresis
Intratubular refractile casts with surrounding syncytial giant cell reaction with chronic tubulointerstitial nephritis and fibrosis characteristic of myeloma cast nephropathy
Kidney Biopsy
CASE STUDYbull A 35 year old African American woman was seen in the clinic for
chronic cough and dyspnea on exertion She gave history of vague symptoms of fatigue and weight loss of 20 Ibs over the last six months
bull List some differentialsbull TB sarcoid lupus thyroid problems PEbull What would you orderbull PPD cbc cmp UA TSH ANA pa and lat cxr
bull Her labs were significant for mildly elevated calcium level and a creatinine of 20 mgdL eGFR 37
bull She had 750 mg of proteinuriaday
bull PPD neg ANA neg TSH and other labs WNL
bull Assuming this is present more than 3 monthshelliphellipwhat is her ckd stage
bull G3b A3
bull What do we still need
CT scan of chest
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileAnterior_mediastinal_mass_thymomajpgCreative Commons License associated httpcreativecommonsorglicensesby20deeden
CXR ndash HILAR LYMPHADENOPATHY
WHATS NEEDED NEXT
bull Biopsy of hilar lymphadenopathy or renal biopsy
bull DX sarcoidosis
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileSarcoidosis_signs_and_symptomsjpgThis work is in the public domain in the United States because it is a work of the United States Federal Government under the terms of Title 17 Chapter 1 Section 105 of the US Code
NEWLY DX CKD
bull 1) urinalysis microscopy ultrasound proteincr ratio
bull If obstruction-treat
bull No obstruction
bull Hx critical (consider myeloma if high risk)
bull glomerular bleeding or albumin in urine
bull Yes workup for glomerular causes (ANArf hep B C upep spep ANCA complement C3 C4)
bull No sterile pyruria-consider interstitial nephritis
bull High risk renovascular disease Evaluate renovascular disease
Additional Online Resources for CKD LearningbullNational Kidney Foundation wwwkidneyorgbullUnited States Renal Data Service wwwusrdsorgbullCDCrsquos CKD Surveillance Project
httpnccdcdcgovckdbullNational Kidney Disease Education Program
(NKDEP) httpnkdepnihgov
BIBLIOGRAPHY
bull Afzali B amp Goldsmith D J (2016 June 29) Statins and chronic kidney disease (G C Curhan amp A M Sheridan Eds) Retrieved 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsstatins-and-chronic-kidney-disease
bull American Diabetes Association Standards of Medical Care in Diabetes (2017) Microvascular complications and foot care Diabetes Care 2017 (40) S88-S98
bull American Diabetes Association Standards of Medical Care in Diabetes (2017) Microvascular complications and foot care Diabetes Care 40 (suppl 1) S88-S98
bull Berns J S (2017 Mar 22) Treatment of anemia in nondialysis chronic kidney disease (T A Golper amp A M Sheridan Eds) Retrieved from UpToDate httpswww-uptodate-comproxywichitaeducontentstreatment-of-anemia-in-nondialysis-chronic-kidney-disease
bull Chan M Dall A T Fletcher K E Lu N amp Trivedi H (2007) Outcomes in patients with chronic kidney disease referred late to nephrologists a meta-analysis American Journal of Medicine 120(12) 1063-1070
bull Coresh J Selvin E amp Stevens L A (2007) Prevalence of chronic kidny disease in the United States JAMA 298(17) doi101001jama298172038
bull de Brito-Ashurst I Varagunam M Raftery M amp Yagoob M (2009) Bicarbonate supplementation slows progression of CKD and improves nutritional status Journal of American Society of Nephrology (20) 2075-2084
BIBLIOGRAPHY
bull Duncan L Heathcoat J Djurdjev O amp Levin A (2001) Screening for renal disease using serum creatinine who are we missing Nephrology Dialysis and Transplant 16(5) 1042-1046
bull Dunkler D Gao P Lee S F Heinz G Clase C M Tobe S Oberbauer R (2015 August 7) Risk prediction for early CKD in type 2 diabetes Retrieved from Clinical Journal of the American Society of Nephrology httpcjasnasnjournalsorgcontent1081371fullsid=61422554-a5f1-41ac-b696-dcd3b12bd268
bull Fatehi P amp Chi-yuan H (September 15 2016) Diagnostic approach to the patient with newly identified chronic kidney disease (G C Curhan amp A M Sheridan Eds) Retrieved May 7 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsdiagnostic-approach-to-the-patient-with-newly-identified-chronic-kidney-disease
bull Fink J e (2009) Chronic Kidney Disease as an Under-Recognized Threat to Patient Safety American journal of kidney diseases the official journal of the National Kidney Foundation 53(4) 681-688
bull Gaffo A L amp Saag K G (2008 Nov) Management of hyperuricemia and gout in CKD doihttpdxdoiorg101053jajkd200807035
bull Hebert L A amp Parikh S V (2014 June 18) Differential diagnosis and evaluation of glomerular disease (R J Glassock amp A Q Lam Eds) Retrieved May 7 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsdifferential-diagnosis-and-evaluation-of-glomerular-disease
bull Inker L Perrone R D Sterns R H amp Forman J P (2017 March 7) Assessment of kidney function Retrieved from UpToDate httpswww-uptodate-comproxywichitaeducontentsassessment-of-kidney-functionsource=search_resultampsearch=creatinineampselectedTitle=1~150
BIBLIOGRAPHY
bull James P A Ortiz E amp Et Al (2014) Evidence based guideline for the management of high blood pressure in adults (JNC) JAMA 311(5) 507-520
bull Kidney Disease Improving Global Outcomes (KDIGO) CKD Work Group (2013 January) KDIGO 2012 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease Retrieved from Kidney International Supplement httpwwwkidney-internationalorg
bull Kunz R Friedrich C Wolbers M amp Mann J F (2008) Meta-analysis effect of monotherapy and combination therapy with inhibitors of the renin angiotensin system on proteinuria in renal disease Annals of Internal Medicine 148(1) 30-48
bull Levey A Stevens L A Schmid C H Castro A F Feldman H I Kusek J W Coresh J (2009) A new equation to estimate glomerular filtration rate Annals of Internal Medicine 150(9) 604-612
bull Levin A Bakris G L Molitch M Smulders M M Williams L A amp Andress D L (2007 Jan) Prevalence of abnormal serum vitamin D PTH calcium and phosphorus in patients with chronic kidney disease results of the study to evaluate early kidney disease Kidney International 71(1) 31-38 Retrieved from PubMED
bull Mahajan A Simoni J Sheather S Broglio K Rajab M amp Wesson D (2010) Daily oral sodium bicarbonate preserves glomerular filtration rate by slowing its decline in early hypertensive nephropathy Kidney International (78_ 303-309
bull Mann J Schmieder R E amp McQueen M (2008) Renal outcomes with telmisartan ramipril or both in people at high vascular risk (the ONTARGET study) a multicentre randomised doubleblind ocntrolled trial Lancet 372(9638) 547-533
BIBLIOGRAPHY
bull Matovinović M S (2009) Pathophysiology and classification of kidney disease Retrieved from The Journal of the International Federation of Clinical Chemistry and Laboratory Medicine httpwwwifccorgifccfilesdocs20010902pdf
bull Moe S Drueke T Lameire N amp Eknoyan G (2007 Jan) Chronic kidney disease-mineral-bone disorder a new paradigmdoi101053jackd200610005
bull Murtagh F E Marsh J E Donohoe P Ekbal N J Sheerin N S amp Harris F E (2007 July) Dialysis or not A comparative survival study of patients over 75 years with chronic kidney disease stage 5 Retrieved from Nephrology Dialysis and Transplant 22(7) httpswwwncbinlmnihgovpubmed17412702
bull National Kidney Foundation (2002) KDOQI clinical practice guidelines for chronic kidney disease evaluation classification andstratification American Journal of Kidney Disease S1-S266
bull National Kidney Foundation (2014 November 5) Fact Sheets Retrieved from httpwwwkidneyorgnewsnewsroomfactsheetsFastFacts
bull Pal S (2012 June 2) Trends in chronic kidney disease Retrieved from US Pharmacist (37)6 httpswwwuspharmacistcomarticletrends-in-chronic-kidney-disease
bull Qunibi W amp Henrich W L (2017 Jan 19) Overview of chronic kidney disease-mineral and bone disorder (J Berns amp A M Sheridan Eds) Retrieved from UpToDate httpswww-uptodate-comoverview-of-chronic-kidney-disease-mineral-and-bone-disorder-ckd-mbd
bull Rosenberg M (2016 Feb 24) Overview of the management of chronic kidney disease in adults (G C Curhan amp A M Sheridan Eds) Retrieved from UpToDate UpToDate httpswww-uptodate-comproxywichitaeducontentsoverview-of-the-management-of-chronic-kidney-disease-in-adults
BIBLIOGRAPHY
bull Szczech L Stewart R C Hsu-Lin S DeLosky R J Astor B C Fox C H Vassalotti J A (2014) Primary care detection of chronic kidney disease in adults with type 2 diabetes The ADD-CKD Study (Awareness Detection and Drug Therapy in type 2 diabetes and chronic kidney disease PLOS doihttpsdoiorg101371journalpone0110535
bull USRDS (2016) Annual data report 2016 Epidemiology of kidney disease in the United States Retrieved from United States Renal Data System httpswwwusrdsorgadraspx
bull Vasudev B amp Vasudev M (2012) A model curriculum for residents rotating in nephrology MedEDPORTAL doihttpdoiorg1015766mep_2374-82658288
bull Wei L MacDonald T M Jennings C Sheng X amp Flynn R W (2013) Estimated GFR reporting is associated with decreased nonsteroidal anti-inflammatory drug prescribing and increased renal function Kidney International (84)1 174-178
chronic kidney disease in primary care
CKD as a Public Health Issue
Slide Number 3
Costs of CKD in 2013 dollarsUSRDS report
Steps to CKD Patient Care
Renal anatomy and physiology
Definition of Chronic Kidney Disease
CKD Risk Factors
Gaps in CKD Diagnosis
Slide Number 10
Steps to CKD Patient Care
creatinine
Glomerular filtration rate
Slide Number 14
Slide Number 15
Use These Equations Cautiously if at all in hellip
lab albumin creatinine ratio
The New CKD Categories
Steps to CKD Patient Care
Slide Number 20
Kidney Involvement in Systemic Diseases
Slide Number 22
Slide Number 23
DysmorphicRenal Hematuria
Slide Number 25
If you have albuminuria or hematuria-order the following labs
Prevalence of Abnormalities of Mineral Metabolism PTH in CKD
Managing CKD-MBD complications
CKD-MBD Testing
Anemia Becomes More Common as Kidney Function Declines
Detect and Manage CKD Complications
Complications-metabolic acidosis
Complications-vascular calcification
Hyperkalemia management
Hyperuricemia levels amp CKD
CKD monitoring levels 345
Slide Number 59
When to Refer to a Nephrologist
When to Refer
Steps to CKD Patient Care
Kidney transplantation
Starting Dialysis in the ElderlyhellipOr Not
Ckd management
Case 1
Slide Number 67
Lab results
Slide Number 69
Hypertensive nephropathy with proteinuria
Slide Number 71
Case 2
Slide Number 73
Management of CKD in Diabetes
Case 3
Case 3
Systemic Lupus Erythematosus (SLE)
SLE ndash Lupus Nephritis
Case 5
Case 5
Slide Number 81
Slide Number 82
Case study
Slide Number 84
CXR ndash Hilar Lymphadenopathy
Whats needed next
Slide Number 87
newly dx ckd
Slide Number 89
Bibliography
bibliography
bibliography
bibliography
bibliography
MANAGEMENT OF CKD IN DIABETESeGFR Recommended
All patients
Yearly measurement of creatinine urinary albumin excretion potassium
45-60 Referral to a nephrologist if possibility for nondiabetickidney disease existsConsider dose adjustment of medicationsMonitor eGFR every 6 monthsMonitor electrolytes bicarbonate hemoglobin calcium phosphorus parathyroid hormone at least yearly
Assure vitamin D sufficiencyConsider bone density testingReferral for dietary counselling
American Diabetes Association Standards of Medical Care in Diabetes Microvascular complications and foot care Diabetes Care 2017 40 (Suppl 1) S88-S98
CASE 3
bull 19 year old African American woman presents to your clinic with complaints of fatigue joint pains a new rash on her face oral ulcer
bull On exam BP 15080 P 88 Afebrile 96 O2 sats on RAbull GEN No respiratory distress at restbull HEENT painless oral ulcer flat rash over malar eminences sparing the nasolabial fold pallor +bull Lungs CTAbull CVS S1S2 regularbull Abdomen soft NTbull Ext left elbow joint and bilateral wrist joints are swollen and tender
bull What would you orderbull CBC CMP ua urine microscopy (microalbumin or urine proteincr ratio) ANA esr RF anti-ccp uric acid TSH
CASE 3
bull Working dx fatigue oral ulcer joint pain
bull Basic Labs Na 135 K 55 Bicarb 18 BUN 50 Cr 35 eGFR 22 Ca 90 ANA + titer 1640
bull UA 3+ blood 3+ protein RBC casts +
bull Given these results what is the most likely diagnosis
bull What would you do
SYSTEMIC LUPUS ERYTHEMATOSUS (SLE)
bull SLE multisystemic disease Etiology unknown
bull Production of autoantibodies and immune complexes formation
bull There is renal involvement in the great majority of patients with SLE at some time of the evolution 66-90
SLE ndash LUPUS NEPHRITIS
bull Race SLE is more commonsevere in African americans than Caucasiansbull
bull Gender female-to-male ratio of 91
bull Age Most patients develop lupus nephritis early in their disease course SLE is more common among women in the third decade of life and lupus nephritis occurs in patients aged 20-40 years
bull Kidney Biopsy For staging lupus nephritis (Class 1-5)
CASE 5bull A 80 year old man who has not seen a PCP in many years
presents to your clinic for weakness for the past few months On further questioning he tells you that his bones also have been hurting lately and he has developed leg swelling in the past month or so
bull On exam bull BP 16090 P 88 Afebrilebull GEN Thin built manbull HEENT pallor presentbull Lungs clearbull CVS S1S2 regular no rub or gallopbull Abdomen soft NTbull Ext 2 + edema
CASE 5
bull Differentials
bull CHF MI Cancer arthritis
bull Labs
bull CBC CMP urine microscopy urine proteincr ratio ESR TSH EKG BNP pa and lat CXR
bull LABS Urine dipstick negative for protein or blood
bull Basic chem bull Na 136 (135-145) K 51 (35-55) Chloride 108 (96-106) Bicarb 25
Given this presentation and the labs (low anion gap and elevated calcium anemia kidney failure) what will you think of What will you order next
Serum and urine protein electrophoresis
Intratubular refractile casts with surrounding syncytial giant cell reaction with chronic tubulointerstitial nephritis and fibrosis characteristic of myeloma cast nephropathy
Kidney Biopsy
CASE STUDYbull A 35 year old African American woman was seen in the clinic for
chronic cough and dyspnea on exertion She gave history of vague symptoms of fatigue and weight loss of 20 Ibs over the last six months
bull List some differentialsbull TB sarcoid lupus thyroid problems PEbull What would you orderbull PPD cbc cmp UA TSH ANA pa and lat cxr
bull Her labs were significant for mildly elevated calcium level and a creatinine of 20 mgdL eGFR 37
bull She had 750 mg of proteinuriaday
bull PPD neg ANA neg TSH and other labs WNL
bull Assuming this is present more than 3 monthshelliphellipwhat is her ckd stage
bull G3b A3
bull What do we still need
CT scan of chest
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileAnterior_mediastinal_mass_thymomajpgCreative Commons License associated httpcreativecommonsorglicensesby20deeden
CXR ndash HILAR LYMPHADENOPATHY
WHATS NEEDED NEXT
bull Biopsy of hilar lymphadenopathy or renal biopsy
bull DX sarcoidosis
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileSarcoidosis_signs_and_symptomsjpgThis work is in the public domain in the United States because it is a work of the United States Federal Government under the terms of Title 17 Chapter 1 Section 105 of the US Code
NEWLY DX CKD
bull 1) urinalysis microscopy ultrasound proteincr ratio
bull If obstruction-treat
bull No obstruction
bull Hx critical (consider myeloma if high risk)
bull glomerular bleeding or albumin in urine
bull Yes workup for glomerular causes (ANArf hep B C upep spep ANCA complement C3 C4)
bull No sterile pyruria-consider interstitial nephritis
bull High risk renovascular disease Evaluate renovascular disease
Additional Online Resources for CKD LearningbullNational Kidney Foundation wwwkidneyorgbullUnited States Renal Data Service wwwusrdsorgbullCDCrsquos CKD Surveillance Project
httpnccdcdcgovckdbullNational Kidney Disease Education Program
(NKDEP) httpnkdepnihgov
BIBLIOGRAPHY
bull Afzali B amp Goldsmith D J (2016 June 29) Statins and chronic kidney disease (G C Curhan amp A M Sheridan Eds) Retrieved 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsstatins-and-chronic-kidney-disease
bull American Diabetes Association Standards of Medical Care in Diabetes (2017) Microvascular complications and foot care Diabetes Care 2017 (40) S88-S98
bull American Diabetes Association Standards of Medical Care in Diabetes (2017) Microvascular complications and foot care Diabetes Care 40 (suppl 1) S88-S98
bull Berns J S (2017 Mar 22) Treatment of anemia in nondialysis chronic kidney disease (T A Golper amp A M Sheridan Eds) Retrieved from UpToDate httpswww-uptodate-comproxywichitaeducontentstreatment-of-anemia-in-nondialysis-chronic-kidney-disease
bull Chan M Dall A T Fletcher K E Lu N amp Trivedi H (2007) Outcomes in patients with chronic kidney disease referred late to nephrologists a meta-analysis American Journal of Medicine 120(12) 1063-1070
bull Coresh J Selvin E amp Stevens L A (2007) Prevalence of chronic kidny disease in the United States JAMA 298(17) doi101001jama298172038
bull de Brito-Ashurst I Varagunam M Raftery M amp Yagoob M (2009) Bicarbonate supplementation slows progression of CKD and improves nutritional status Journal of American Society of Nephrology (20) 2075-2084
BIBLIOGRAPHY
bull Duncan L Heathcoat J Djurdjev O amp Levin A (2001) Screening for renal disease using serum creatinine who are we missing Nephrology Dialysis and Transplant 16(5) 1042-1046
bull Dunkler D Gao P Lee S F Heinz G Clase C M Tobe S Oberbauer R (2015 August 7) Risk prediction for early CKD in type 2 diabetes Retrieved from Clinical Journal of the American Society of Nephrology httpcjasnasnjournalsorgcontent1081371fullsid=61422554-a5f1-41ac-b696-dcd3b12bd268
bull Fatehi P amp Chi-yuan H (September 15 2016) Diagnostic approach to the patient with newly identified chronic kidney disease (G C Curhan amp A M Sheridan Eds) Retrieved May 7 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsdiagnostic-approach-to-the-patient-with-newly-identified-chronic-kidney-disease
bull Fink J e (2009) Chronic Kidney Disease as an Under-Recognized Threat to Patient Safety American journal of kidney diseases the official journal of the National Kidney Foundation 53(4) 681-688
bull Gaffo A L amp Saag K G (2008 Nov) Management of hyperuricemia and gout in CKD doihttpdxdoiorg101053jajkd200807035
bull Hebert L A amp Parikh S V (2014 June 18) Differential diagnosis and evaluation of glomerular disease (R J Glassock amp A Q Lam Eds) Retrieved May 7 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsdifferential-diagnosis-and-evaluation-of-glomerular-disease
bull Inker L Perrone R D Sterns R H amp Forman J P (2017 March 7) Assessment of kidney function Retrieved from UpToDate httpswww-uptodate-comproxywichitaeducontentsassessment-of-kidney-functionsource=search_resultampsearch=creatinineampselectedTitle=1~150
BIBLIOGRAPHY
bull James P A Ortiz E amp Et Al (2014) Evidence based guideline for the management of high blood pressure in adults (JNC) JAMA 311(5) 507-520
bull Kidney Disease Improving Global Outcomes (KDIGO) CKD Work Group (2013 January) KDIGO 2012 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease Retrieved from Kidney International Supplement httpwwwkidney-internationalorg
bull Kunz R Friedrich C Wolbers M amp Mann J F (2008) Meta-analysis effect of monotherapy and combination therapy with inhibitors of the renin angiotensin system on proteinuria in renal disease Annals of Internal Medicine 148(1) 30-48
bull Levey A Stevens L A Schmid C H Castro A F Feldman H I Kusek J W Coresh J (2009) A new equation to estimate glomerular filtration rate Annals of Internal Medicine 150(9) 604-612
bull Levin A Bakris G L Molitch M Smulders M M Williams L A amp Andress D L (2007 Jan) Prevalence of abnormal serum vitamin D PTH calcium and phosphorus in patients with chronic kidney disease results of the study to evaluate early kidney disease Kidney International 71(1) 31-38 Retrieved from PubMED
bull Mahajan A Simoni J Sheather S Broglio K Rajab M amp Wesson D (2010) Daily oral sodium bicarbonate preserves glomerular filtration rate by slowing its decline in early hypertensive nephropathy Kidney International (78_ 303-309
bull Mann J Schmieder R E amp McQueen M (2008) Renal outcomes with telmisartan ramipril or both in people at high vascular risk (the ONTARGET study) a multicentre randomised doubleblind ocntrolled trial Lancet 372(9638) 547-533
BIBLIOGRAPHY
bull Matovinović M S (2009) Pathophysiology and classification of kidney disease Retrieved from The Journal of the International Federation of Clinical Chemistry and Laboratory Medicine httpwwwifccorgifccfilesdocs20010902pdf
bull Moe S Drueke T Lameire N amp Eknoyan G (2007 Jan) Chronic kidney disease-mineral-bone disorder a new paradigmdoi101053jackd200610005
bull Murtagh F E Marsh J E Donohoe P Ekbal N J Sheerin N S amp Harris F E (2007 July) Dialysis or not A comparative survival study of patients over 75 years with chronic kidney disease stage 5 Retrieved from Nephrology Dialysis and Transplant 22(7) httpswwwncbinlmnihgovpubmed17412702
bull National Kidney Foundation (2002) KDOQI clinical practice guidelines for chronic kidney disease evaluation classification andstratification American Journal of Kidney Disease S1-S266
bull National Kidney Foundation (2014 November 5) Fact Sheets Retrieved from httpwwwkidneyorgnewsnewsroomfactsheetsFastFacts
bull Pal S (2012 June 2) Trends in chronic kidney disease Retrieved from US Pharmacist (37)6 httpswwwuspharmacistcomarticletrends-in-chronic-kidney-disease
bull Qunibi W amp Henrich W L (2017 Jan 19) Overview of chronic kidney disease-mineral and bone disorder (J Berns amp A M Sheridan Eds) Retrieved from UpToDate httpswww-uptodate-comoverview-of-chronic-kidney-disease-mineral-and-bone-disorder-ckd-mbd
bull Rosenberg M (2016 Feb 24) Overview of the management of chronic kidney disease in adults (G C Curhan amp A M Sheridan Eds) Retrieved from UpToDate UpToDate httpswww-uptodate-comproxywichitaeducontentsoverview-of-the-management-of-chronic-kidney-disease-in-adults
BIBLIOGRAPHY
bull Szczech L Stewart R C Hsu-Lin S DeLosky R J Astor B C Fox C H Vassalotti J A (2014) Primary care detection of chronic kidney disease in adults with type 2 diabetes The ADD-CKD Study (Awareness Detection and Drug Therapy in type 2 diabetes and chronic kidney disease PLOS doihttpsdoiorg101371journalpone0110535
bull USRDS (2016) Annual data report 2016 Epidemiology of kidney disease in the United States Retrieved from United States Renal Data System httpswwwusrdsorgadraspx
bull Vasudev B amp Vasudev M (2012) A model curriculum for residents rotating in nephrology MedEDPORTAL doihttpdoiorg1015766mep_2374-82658288
bull Wei L MacDonald T M Jennings C Sheng X amp Flynn R W (2013) Estimated GFR reporting is associated with decreased nonsteroidal anti-inflammatory drug prescribing and increased renal function Kidney International (84)1 174-178
chronic kidney disease in primary care
CKD as a Public Health Issue
Slide Number 3
Costs of CKD in 2013 dollarsUSRDS report
Steps to CKD Patient Care
Renal anatomy and physiology
Definition of Chronic Kidney Disease
CKD Risk Factors
Gaps in CKD Diagnosis
Slide Number 10
Steps to CKD Patient Care
creatinine
Glomerular filtration rate
Slide Number 14
Slide Number 15
Use These Equations Cautiously if at all in hellip
lab albumin creatinine ratio
The New CKD Categories
Steps to CKD Patient Care
Slide Number 20
Kidney Involvement in Systemic Diseases
Slide Number 22
Slide Number 23
DysmorphicRenal Hematuria
Slide Number 25
If you have albuminuria or hematuria-order the following labs
Prevalence of Abnormalities of Mineral Metabolism PTH in CKD
Managing CKD-MBD complications
CKD-MBD Testing
Anemia Becomes More Common as Kidney Function Declines
Detect and Manage CKD Complications
Complications-metabolic acidosis
Complications-vascular calcification
Hyperkalemia management
Hyperuricemia levels amp CKD
CKD monitoring levels 345
Slide Number 59
When to Refer to a Nephrologist
When to Refer
Steps to CKD Patient Care
Kidney transplantation
Starting Dialysis in the ElderlyhellipOr Not
Ckd management
Case 1
Slide Number 67
Lab results
Slide Number 69
Hypertensive nephropathy with proteinuria
Slide Number 71
Case 2
Slide Number 73
Management of CKD in Diabetes
Case 3
Case 3
Systemic Lupus Erythematosus (SLE)
SLE ndash Lupus Nephritis
Case 5
Case 5
Slide Number 81
Slide Number 82
Case study
Slide Number 84
CXR ndash Hilar Lymphadenopathy
Whats needed next
Slide Number 87
newly dx ckd
Slide Number 89
Bibliography
bibliography
bibliography
bibliography
bibliography
CASE 3
bull 19 year old African American woman presents to your clinic with complaints of fatigue joint pains a new rash on her face oral ulcer
bull On exam BP 15080 P 88 Afebrile 96 O2 sats on RAbull GEN No respiratory distress at restbull HEENT painless oral ulcer flat rash over malar eminences sparing the nasolabial fold pallor +bull Lungs CTAbull CVS S1S2 regularbull Abdomen soft NTbull Ext left elbow joint and bilateral wrist joints are swollen and tender
bull What would you orderbull CBC CMP ua urine microscopy (microalbumin or urine proteincr ratio) ANA esr RF anti-ccp uric acid TSH
CASE 3
bull Working dx fatigue oral ulcer joint pain
bull Basic Labs Na 135 K 55 Bicarb 18 BUN 50 Cr 35 eGFR 22 Ca 90 ANA + titer 1640
bull UA 3+ blood 3+ protein RBC casts +
bull Given these results what is the most likely diagnosis
bull What would you do
SYSTEMIC LUPUS ERYTHEMATOSUS (SLE)
bull SLE multisystemic disease Etiology unknown
bull Production of autoantibodies and immune complexes formation
bull There is renal involvement in the great majority of patients with SLE at some time of the evolution 66-90
SLE ndash LUPUS NEPHRITIS
bull Race SLE is more commonsevere in African americans than Caucasiansbull
bull Gender female-to-male ratio of 91
bull Age Most patients develop lupus nephritis early in their disease course SLE is more common among women in the third decade of life and lupus nephritis occurs in patients aged 20-40 years
bull Kidney Biopsy For staging lupus nephritis (Class 1-5)
CASE 5bull A 80 year old man who has not seen a PCP in many years
presents to your clinic for weakness for the past few months On further questioning he tells you that his bones also have been hurting lately and he has developed leg swelling in the past month or so
bull On exam bull BP 16090 P 88 Afebrilebull GEN Thin built manbull HEENT pallor presentbull Lungs clearbull CVS S1S2 regular no rub or gallopbull Abdomen soft NTbull Ext 2 + edema
CASE 5
bull Differentials
bull CHF MI Cancer arthritis
bull Labs
bull CBC CMP urine microscopy urine proteincr ratio ESR TSH EKG BNP pa and lat CXR
bull LABS Urine dipstick negative for protein or blood
bull Basic chem bull Na 136 (135-145) K 51 (35-55) Chloride 108 (96-106) Bicarb 25
Given this presentation and the labs (low anion gap and elevated calcium anemia kidney failure) what will you think of What will you order next
Serum and urine protein electrophoresis
Intratubular refractile casts with surrounding syncytial giant cell reaction with chronic tubulointerstitial nephritis and fibrosis characteristic of myeloma cast nephropathy
Kidney Biopsy
CASE STUDYbull A 35 year old African American woman was seen in the clinic for
chronic cough and dyspnea on exertion She gave history of vague symptoms of fatigue and weight loss of 20 Ibs over the last six months
bull List some differentialsbull TB sarcoid lupus thyroid problems PEbull What would you orderbull PPD cbc cmp UA TSH ANA pa and lat cxr
bull Her labs were significant for mildly elevated calcium level and a creatinine of 20 mgdL eGFR 37
bull She had 750 mg of proteinuriaday
bull PPD neg ANA neg TSH and other labs WNL
bull Assuming this is present more than 3 monthshelliphellipwhat is her ckd stage
bull G3b A3
bull What do we still need
CT scan of chest
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileAnterior_mediastinal_mass_thymomajpgCreative Commons License associated httpcreativecommonsorglicensesby20deeden
CXR ndash HILAR LYMPHADENOPATHY
WHATS NEEDED NEXT
bull Biopsy of hilar lymphadenopathy or renal biopsy
bull DX sarcoidosis
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileSarcoidosis_signs_and_symptomsjpgThis work is in the public domain in the United States because it is a work of the United States Federal Government under the terms of Title 17 Chapter 1 Section 105 of the US Code
NEWLY DX CKD
bull 1) urinalysis microscopy ultrasound proteincr ratio
bull If obstruction-treat
bull No obstruction
bull Hx critical (consider myeloma if high risk)
bull glomerular bleeding or albumin in urine
bull Yes workup for glomerular causes (ANArf hep B C upep spep ANCA complement C3 C4)
bull No sterile pyruria-consider interstitial nephritis
bull High risk renovascular disease Evaluate renovascular disease
Additional Online Resources for CKD LearningbullNational Kidney Foundation wwwkidneyorgbullUnited States Renal Data Service wwwusrdsorgbullCDCrsquos CKD Surveillance Project
httpnccdcdcgovckdbullNational Kidney Disease Education Program
(NKDEP) httpnkdepnihgov
BIBLIOGRAPHY
bull Afzali B amp Goldsmith D J (2016 June 29) Statins and chronic kidney disease (G C Curhan amp A M Sheridan Eds) Retrieved 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsstatins-and-chronic-kidney-disease
bull American Diabetes Association Standards of Medical Care in Diabetes (2017) Microvascular complications and foot care Diabetes Care 2017 (40) S88-S98
bull American Diabetes Association Standards of Medical Care in Diabetes (2017) Microvascular complications and foot care Diabetes Care 40 (suppl 1) S88-S98
bull Berns J S (2017 Mar 22) Treatment of anemia in nondialysis chronic kidney disease (T A Golper amp A M Sheridan Eds) Retrieved from UpToDate httpswww-uptodate-comproxywichitaeducontentstreatment-of-anemia-in-nondialysis-chronic-kidney-disease
bull Chan M Dall A T Fletcher K E Lu N amp Trivedi H (2007) Outcomes in patients with chronic kidney disease referred late to nephrologists a meta-analysis American Journal of Medicine 120(12) 1063-1070
bull Coresh J Selvin E amp Stevens L A (2007) Prevalence of chronic kidny disease in the United States JAMA 298(17) doi101001jama298172038
bull de Brito-Ashurst I Varagunam M Raftery M amp Yagoob M (2009) Bicarbonate supplementation slows progression of CKD and improves nutritional status Journal of American Society of Nephrology (20) 2075-2084
BIBLIOGRAPHY
bull Duncan L Heathcoat J Djurdjev O amp Levin A (2001) Screening for renal disease using serum creatinine who are we missing Nephrology Dialysis and Transplant 16(5) 1042-1046
bull Dunkler D Gao P Lee S F Heinz G Clase C M Tobe S Oberbauer R (2015 August 7) Risk prediction for early CKD in type 2 diabetes Retrieved from Clinical Journal of the American Society of Nephrology httpcjasnasnjournalsorgcontent1081371fullsid=61422554-a5f1-41ac-b696-dcd3b12bd268
bull Fatehi P amp Chi-yuan H (September 15 2016) Diagnostic approach to the patient with newly identified chronic kidney disease (G C Curhan amp A M Sheridan Eds) Retrieved May 7 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsdiagnostic-approach-to-the-patient-with-newly-identified-chronic-kidney-disease
bull Fink J e (2009) Chronic Kidney Disease as an Under-Recognized Threat to Patient Safety American journal of kidney diseases the official journal of the National Kidney Foundation 53(4) 681-688
bull Gaffo A L amp Saag K G (2008 Nov) Management of hyperuricemia and gout in CKD doihttpdxdoiorg101053jajkd200807035
bull Hebert L A amp Parikh S V (2014 June 18) Differential diagnosis and evaluation of glomerular disease (R J Glassock amp A Q Lam Eds) Retrieved May 7 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsdifferential-diagnosis-and-evaluation-of-glomerular-disease
bull Inker L Perrone R D Sterns R H amp Forman J P (2017 March 7) Assessment of kidney function Retrieved from UpToDate httpswww-uptodate-comproxywichitaeducontentsassessment-of-kidney-functionsource=search_resultampsearch=creatinineampselectedTitle=1~150
BIBLIOGRAPHY
bull James P A Ortiz E amp Et Al (2014) Evidence based guideline for the management of high blood pressure in adults (JNC) JAMA 311(5) 507-520
bull Kidney Disease Improving Global Outcomes (KDIGO) CKD Work Group (2013 January) KDIGO 2012 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease Retrieved from Kidney International Supplement httpwwwkidney-internationalorg
bull Kunz R Friedrich C Wolbers M amp Mann J F (2008) Meta-analysis effect of monotherapy and combination therapy with inhibitors of the renin angiotensin system on proteinuria in renal disease Annals of Internal Medicine 148(1) 30-48
bull Levey A Stevens L A Schmid C H Castro A F Feldman H I Kusek J W Coresh J (2009) A new equation to estimate glomerular filtration rate Annals of Internal Medicine 150(9) 604-612
bull Levin A Bakris G L Molitch M Smulders M M Williams L A amp Andress D L (2007 Jan) Prevalence of abnormal serum vitamin D PTH calcium and phosphorus in patients with chronic kidney disease results of the study to evaluate early kidney disease Kidney International 71(1) 31-38 Retrieved from PubMED
bull Mahajan A Simoni J Sheather S Broglio K Rajab M amp Wesson D (2010) Daily oral sodium bicarbonate preserves glomerular filtration rate by slowing its decline in early hypertensive nephropathy Kidney International (78_ 303-309
bull Mann J Schmieder R E amp McQueen M (2008) Renal outcomes with telmisartan ramipril or both in people at high vascular risk (the ONTARGET study) a multicentre randomised doubleblind ocntrolled trial Lancet 372(9638) 547-533
BIBLIOGRAPHY
bull Matovinović M S (2009) Pathophysiology and classification of kidney disease Retrieved from The Journal of the International Federation of Clinical Chemistry and Laboratory Medicine httpwwwifccorgifccfilesdocs20010902pdf
bull Moe S Drueke T Lameire N amp Eknoyan G (2007 Jan) Chronic kidney disease-mineral-bone disorder a new paradigmdoi101053jackd200610005
bull Murtagh F E Marsh J E Donohoe P Ekbal N J Sheerin N S amp Harris F E (2007 July) Dialysis or not A comparative survival study of patients over 75 years with chronic kidney disease stage 5 Retrieved from Nephrology Dialysis and Transplant 22(7) httpswwwncbinlmnihgovpubmed17412702
bull National Kidney Foundation (2002) KDOQI clinical practice guidelines for chronic kidney disease evaluation classification andstratification American Journal of Kidney Disease S1-S266
bull National Kidney Foundation (2014 November 5) Fact Sheets Retrieved from httpwwwkidneyorgnewsnewsroomfactsheetsFastFacts
bull Pal S (2012 June 2) Trends in chronic kidney disease Retrieved from US Pharmacist (37)6 httpswwwuspharmacistcomarticletrends-in-chronic-kidney-disease
bull Qunibi W amp Henrich W L (2017 Jan 19) Overview of chronic kidney disease-mineral and bone disorder (J Berns amp A M Sheridan Eds) Retrieved from UpToDate httpswww-uptodate-comoverview-of-chronic-kidney-disease-mineral-and-bone-disorder-ckd-mbd
bull Rosenberg M (2016 Feb 24) Overview of the management of chronic kidney disease in adults (G C Curhan amp A M Sheridan Eds) Retrieved from UpToDate UpToDate httpswww-uptodate-comproxywichitaeducontentsoverview-of-the-management-of-chronic-kidney-disease-in-adults
BIBLIOGRAPHY
bull Szczech L Stewart R C Hsu-Lin S DeLosky R J Astor B C Fox C H Vassalotti J A (2014) Primary care detection of chronic kidney disease in adults with type 2 diabetes The ADD-CKD Study (Awareness Detection and Drug Therapy in type 2 diabetes and chronic kidney disease PLOS doihttpsdoiorg101371journalpone0110535
bull USRDS (2016) Annual data report 2016 Epidemiology of kidney disease in the United States Retrieved from United States Renal Data System httpswwwusrdsorgadraspx
bull Vasudev B amp Vasudev M (2012) A model curriculum for residents rotating in nephrology MedEDPORTAL doihttpdoiorg1015766mep_2374-82658288
bull Wei L MacDonald T M Jennings C Sheng X amp Flynn R W (2013) Estimated GFR reporting is associated with decreased nonsteroidal anti-inflammatory drug prescribing and increased renal function Kidney International (84)1 174-178
chronic kidney disease in primary care
CKD as a Public Health Issue
Slide Number 3
Costs of CKD in 2013 dollarsUSRDS report
Steps to CKD Patient Care
Renal anatomy and physiology
Definition of Chronic Kidney Disease
CKD Risk Factors
Gaps in CKD Diagnosis
Slide Number 10
Steps to CKD Patient Care
creatinine
Glomerular filtration rate
Slide Number 14
Slide Number 15
Use These Equations Cautiously if at all in hellip
lab albumin creatinine ratio
The New CKD Categories
Steps to CKD Patient Care
Slide Number 20
Kidney Involvement in Systemic Diseases
Slide Number 22
Slide Number 23
DysmorphicRenal Hematuria
Slide Number 25
If you have albuminuria or hematuria-order the following labs
Prevalence of Abnormalities of Mineral Metabolism PTH in CKD
Managing CKD-MBD complications
CKD-MBD Testing
Anemia Becomes More Common as Kidney Function Declines
Detect and Manage CKD Complications
Complications-metabolic acidosis
Complications-vascular calcification
Hyperkalemia management
Hyperuricemia levels amp CKD
CKD monitoring levels 345
Slide Number 59
When to Refer to a Nephrologist
When to Refer
Steps to CKD Patient Care
Kidney transplantation
Starting Dialysis in the ElderlyhellipOr Not
Ckd management
Case 1
Slide Number 67
Lab results
Slide Number 69
Hypertensive nephropathy with proteinuria
Slide Number 71
Case 2
Slide Number 73
Management of CKD in Diabetes
Case 3
Case 3
Systemic Lupus Erythematosus (SLE)
SLE ndash Lupus Nephritis
Case 5
Case 5
Slide Number 81
Slide Number 82
Case study
Slide Number 84
CXR ndash Hilar Lymphadenopathy
Whats needed next
Slide Number 87
newly dx ckd
Slide Number 89
Bibliography
bibliography
bibliography
bibliography
bibliography
CASE 3
bull Working dx fatigue oral ulcer joint pain
bull Basic Labs Na 135 K 55 Bicarb 18 BUN 50 Cr 35 eGFR 22 Ca 90 ANA + titer 1640
bull UA 3+ blood 3+ protein RBC casts +
bull Given these results what is the most likely diagnosis
bull What would you do
SYSTEMIC LUPUS ERYTHEMATOSUS (SLE)
bull SLE multisystemic disease Etiology unknown
bull Production of autoantibodies and immune complexes formation
bull There is renal involvement in the great majority of patients with SLE at some time of the evolution 66-90
SLE ndash LUPUS NEPHRITIS
bull Race SLE is more commonsevere in African americans than Caucasiansbull
bull Gender female-to-male ratio of 91
bull Age Most patients develop lupus nephritis early in their disease course SLE is more common among women in the third decade of life and lupus nephritis occurs in patients aged 20-40 years
bull Kidney Biopsy For staging lupus nephritis (Class 1-5)
CASE 5bull A 80 year old man who has not seen a PCP in many years
presents to your clinic for weakness for the past few months On further questioning he tells you that his bones also have been hurting lately and he has developed leg swelling in the past month or so
bull On exam bull BP 16090 P 88 Afebrilebull GEN Thin built manbull HEENT pallor presentbull Lungs clearbull CVS S1S2 regular no rub or gallopbull Abdomen soft NTbull Ext 2 + edema
CASE 5
bull Differentials
bull CHF MI Cancer arthritis
bull Labs
bull CBC CMP urine microscopy urine proteincr ratio ESR TSH EKG BNP pa and lat CXR
bull LABS Urine dipstick negative for protein or blood
bull Basic chem bull Na 136 (135-145) K 51 (35-55) Chloride 108 (96-106) Bicarb 25
Given this presentation and the labs (low anion gap and elevated calcium anemia kidney failure) what will you think of What will you order next
Serum and urine protein electrophoresis
Intratubular refractile casts with surrounding syncytial giant cell reaction with chronic tubulointerstitial nephritis and fibrosis characteristic of myeloma cast nephropathy
Kidney Biopsy
CASE STUDYbull A 35 year old African American woman was seen in the clinic for
chronic cough and dyspnea on exertion She gave history of vague symptoms of fatigue and weight loss of 20 Ibs over the last six months
bull List some differentialsbull TB sarcoid lupus thyroid problems PEbull What would you orderbull PPD cbc cmp UA TSH ANA pa and lat cxr
bull Her labs were significant for mildly elevated calcium level and a creatinine of 20 mgdL eGFR 37
bull She had 750 mg of proteinuriaday
bull PPD neg ANA neg TSH and other labs WNL
bull Assuming this is present more than 3 monthshelliphellipwhat is her ckd stage
bull G3b A3
bull What do we still need
CT scan of chest
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileAnterior_mediastinal_mass_thymomajpgCreative Commons License associated httpcreativecommonsorglicensesby20deeden
CXR ndash HILAR LYMPHADENOPATHY
WHATS NEEDED NEXT
bull Biopsy of hilar lymphadenopathy or renal biopsy
bull DX sarcoidosis
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileSarcoidosis_signs_and_symptomsjpgThis work is in the public domain in the United States because it is a work of the United States Federal Government under the terms of Title 17 Chapter 1 Section 105 of the US Code
NEWLY DX CKD
bull 1) urinalysis microscopy ultrasound proteincr ratio
bull If obstruction-treat
bull No obstruction
bull Hx critical (consider myeloma if high risk)
bull glomerular bleeding or albumin in urine
bull Yes workup for glomerular causes (ANArf hep B C upep spep ANCA complement C3 C4)
bull No sterile pyruria-consider interstitial nephritis
bull High risk renovascular disease Evaluate renovascular disease
Additional Online Resources for CKD LearningbullNational Kidney Foundation wwwkidneyorgbullUnited States Renal Data Service wwwusrdsorgbullCDCrsquos CKD Surveillance Project
httpnccdcdcgovckdbullNational Kidney Disease Education Program
(NKDEP) httpnkdepnihgov
BIBLIOGRAPHY
bull Afzali B amp Goldsmith D J (2016 June 29) Statins and chronic kidney disease (G C Curhan amp A M Sheridan Eds) Retrieved 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsstatins-and-chronic-kidney-disease
bull American Diabetes Association Standards of Medical Care in Diabetes (2017) Microvascular complications and foot care Diabetes Care 2017 (40) S88-S98
bull American Diabetes Association Standards of Medical Care in Diabetes (2017) Microvascular complications and foot care Diabetes Care 40 (suppl 1) S88-S98
bull Berns J S (2017 Mar 22) Treatment of anemia in nondialysis chronic kidney disease (T A Golper amp A M Sheridan Eds) Retrieved from UpToDate httpswww-uptodate-comproxywichitaeducontentstreatment-of-anemia-in-nondialysis-chronic-kidney-disease
bull Chan M Dall A T Fletcher K E Lu N amp Trivedi H (2007) Outcomes in patients with chronic kidney disease referred late to nephrologists a meta-analysis American Journal of Medicine 120(12) 1063-1070
bull Coresh J Selvin E amp Stevens L A (2007) Prevalence of chronic kidny disease in the United States JAMA 298(17) doi101001jama298172038
bull de Brito-Ashurst I Varagunam M Raftery M amp Yagoob M (2009) Bicarbonate supplementation slows progression of CKD and improves nutritional status Journal of American Society of Nephrology (20) 2075-2084
BIBLIOGRAPHY
bull Duncan L Heathcoat J Djurdjev O amp Levin A (2001) Screening for renal disease using serum creatinine who are we missing Nephrology Dialysis and Transplant 16(5) 1042-1046
bull Dunkler D Gao P Lee S F Heinz G Clase C M Tobe S Oberbauer R (2015 August 7) Risk prediction for early CKD in type 2 diabetes Retrieved from Clinical Journal of the American Society of Nephrology httpcjasnasnjournalsorgcontent1081371fullsid=61422554-a5f1-41ac-b696-dcd3b12bd268
bull Fatehi P amp Chi-yuan H (September 15 2016) Diagnostic approach to the patient with newly identified chronic kidney disease (G C Curhan amp A M Sheridan Eds) Retrieved May 7 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsdiagnostic-approach-to-the-patient-with-newly-identified-chronic-kidney-disease
bull Fink J e (2009) Chronic Kidney Disease as an Under-Recognized Threat to Patient Safety American journal of kidney diseases the official journal of the National Kidney Foundation 53(4) 681-688
bull Gaffo A L amp Saag K G (2008 Nov) Management of hyperuricemia and gout in CKD doihttpdxdoiorg101053jajkd200807035
bull Hebert L A amp Parikh S V (2014 June 18) Differential diagnosis and evaluation of glomerular disease (R J Glassock amp A Q Lam Eds) Retrieved May 7 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsdifferential-diagnosis-and-evaluation-of-glomerular-disease
bull Inker L Perrone R D Sterns R H amp Forman J P (2017 March 7) Assessment of kidney function Retrieved from UpToDate httpswww-uptodate-comproxywichitaeducontentsassessment-of-kidney-functionsource=search_resultampsearch=creatinineampselectedTitle=1~150
BIBLIOGRAPHY
bull James P A Ortiz E amp Et Al (2014) Evidence based guideline for the management of high blood pressure in adults (JNC) JAMA 311(5) 507-520
bull Kidney Disease Improving Global Outcomes (KDIGO) CKD Work Group (2013 January) KDIGO 2012 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease Retrieved from Kidney International Supplement httpwwwkidney-internationalorg
bull Kunz R Friedrich C Wolbers M amp Mann J F (2008) Meta-analysis effect of monotherapy and combination therapy with inhibitors of the renin angiotensin system on proteinuria in renal disease Annals of Internal Medicine 148(1) 30-48
bull Levey A Stevens L A Schmid C H Castro A F Feldman H I Kusek J W Coresh J (2009) A new equation to estimate glomerular filtration rate Annals of Internal Medicine 150(9) 604-612
bull Levin A Bakris G L Molitch M Smulders M M Williams L A amp Andress D L (2007 Jan) Prevalence of abnormal serum vitamin D PTH calcium and phosphorus in patients with chronic kidney disease results of the study to evaluate early kidney disease Kidney International 71(1) 31-38 Retrieved from PubMED
bull Mahajan A Simoni J Sheather S Broglio K Rajab M amp Wesson D (2010) Daily oral sodium bicarbonate preserves glomerular filtration rate by slowing its decline in early hypertensive nephropathy Kidney International (78_ 303-309
bull Mann J Schmieder R E amp McQueen M (2008) Renal outcomes with telmisartan ramipril or both in people at high vascular risk (the ONTARGET study) a multicentre randomised doubleblind ocntrolled trial Lancet 372(9638) 547-533
BIBLIOGRAPHY
bull Matovinović M S (2009) Pathophysiology and classification of kidney disease Retrieved from The Journal of the International Federation of Clinical Chemistry and Laboratory Medicine httpwwwifccorgifccfilesdocs20010902pdf
bull Moe S Drueke T Lameire N amp Eknoyan G (2007 Jan) Chronic kidney disease-mineral-bone disorder a new paradigmdoi101053jackd200610005
bull Murtagh F E Marsh J E Donohoe P Ekbal N J Sheerin N S amp Harris F E (2007 July) Dialysis or not A comparative survival study of patients over 75 years with chronic kidney disease stage 5 Retrieved from Nephrology Dialysis and Transplant 22(7) httpswwwncbinlmnihgovpubmed17412702
bull National Kidney Foundation (2002) KDOQI clinical practice guidelines for chronic kidney disease evaluation classification andstratification American Journal of Kidney Disease S1-S266
bull National Kidney Foundation (2014 November 5) Fact Sheets Retrieved from httpwwwkidneyorgnewsnewsroomfactsheetsFastFacts
bull Pal S (2012 June 2) Trends in chronic kidney disease Retrieved from US Pharmacist (37)6 httpswwwuspharmacistcomarticletrends-in-chronic-kidney-disease
bull Qunibi W amp Henrich W L (2017 Jan 19) Overview of chronic kidney disease-mineral and bone disorder (J Berns amp A M Sheridan Eds) Retrieved from UpToDate httpswww-uptodate-comoverview-of-chronic-kidney-disease-mineral-and-bone-disorder-ckd-mbd
bull Rosenberg M (2016 Feb 24) Overview of the management of chronic kidney disease in adults (G C Curhan amp A M Sheridan Eds) Retrieved from UpToDate UpToDate httpswww-uptodate-comproxywichitaeducontentsoverview-of-the-management-of-chronic-kidney-disease-in-adults
BIBLIOGRAPHY
bull Szczech L Stewart R C Hsu-Lin S DeLosky R J Astor B C Fox C H Vassalotti J A (2014) Primary care detection of chronic kidney disease in adults with type 2 diabetes The ADD-CKD Study (Awareness Detection and Drug Therapy in type 2 diabetes and chronic kidney disease PLOS doihttpsdoiorg101371journalpone0110535
bull USRDS (2016) Annual data report 2016 Epidemiology of kidney disease in the United States Retrieved from United States Renal Data System httpswwwusrdsorgadraspx
bull Vasudev B amp Vasudev M (2012) A model curriculum for residents rotating in nephrology MedEDPORTAL doihttpdoiorg1015766mep_2374-82658288
bull Wei L MacDonald T M Jennings C Sheng X amp Flynn R W (2013) Estimated GFR reporting is associated with decreased nonsteroidal anti-inflammatory drug prescribing and increased renal function Kidney International (84)1 174-178
chronic kidney disease in primary care
CKD as a Public Health Issue
Slide Number 3
Costs of CKD in 2013 dollarsUSRDS report
Steps to CKD Patient Care
Renal anatomy and physiology
Definition of Chronic Kidney Disease
CKD Risk Factors
Gaps in CKD Diagnosis
Slide Number 10
Steps to CKD Patient Care
creatinine
Glomerular filtration rate
Slide Number 14
Slide Number 15
Use These Equations Cautiously if at all in hellip
lab albumin creatinine ratio
The New CKD Categories
Steps to CKD Patient Care
Slide Number 20
Kidney Involvement in Systemic Diseases
Slide Number 22
Slide Number 23
DysmorphicRenal Hematuria
Slide Number 25
If you have albuminuria or hematuria-order the following labs
Prevalence of Abnormalities of Mineral Metabolism PTH in CKD
Managing CKD-MBD complications
CKD-MBD Testing
Anemia Becomes More Common as Kidney Function Declines
Detect and Manage CKD Complications
Complications-metabolic acidosis
Complications-vascular calcification
Hyperkalemia management
Hyperuricemia levels amp CKD
CKD monitoring levels 345
Slide Number 59
When to Refer to a Nephrologist
When to Refer
Steps to CKD Patient Care
Kidney transplantation
Starting Dialysis in the ElderlyhellipOr Not
Ckd management
Case 1
Slide Number 67
Lab results
Slide Number 69
Hypertensive nephropathy with proteinuria
Slide Number 71
Case 2
Slide Number 73
Management of CKD in Diabetes
Case 3
Case 3
Systemic Lupus Erythematosus (SLE)
SLE ndash Lupus Nephritis
Case 5
Case 5
Slide Number 81
Slide Number 82
Case study
Slide Number 84
CXR ndash Hilar Lymphadenopathy
Whats needed next
Slide Number 87
newly dx ckd
Slide Number 89
Bibliography
bibliography
bibliography
bibliography
bibliography
SYSTEMIC LUPUS ERYTHEMATOSUS (SLE)
bull SLE multisystemic disease Etiology unknown
bull Production of autoantibodies and immune complexes formation
bull There is renal involvement in the great majority of patients with SLE at some time of the evolution 66-90
SLE ndash LUPUS NEPHRITIS
bull Race SLE is more commonsevere in African americans than Caucasiansbull
bull Gender female-to-male ratio of 91
bull Age Most patients develop lupus nephritis early in their disease course SLE is more common among women in the third decade of life and lupus nephritis occurs in patients aged 20-40 years
bull Kidney Biopsy For staging lupus nephritis (Class 1-5)
CASE 5bull A 80 year old man who has not seen a PCP in many years
presents to your clinic for weakness for the past few months On further questioning he tells you that his bones also have been hurting lately and he has developed leg swelling in the past month or so
bull On exam bull BP 16090 P 88 Afebrilebull GEN Thin built manbull HEENT pallor presentbull Lungs clearbull CVS S1S2 regular no rub or gallopbull Abdomen soft NTbull Ext 2 + edema
CASE 5
bull Differentials
bull CHF MI Cancer arthritis
bull Labs
bull CBC CMP urine microscopy urine proteincr ratio ESR TSH EKG BNP pa and lat CXR
bull LABS Urine dipstick negative for protein or blood
bull Basic chem bull Na 136 (135-145) K 51 (35-55) Chloride 108 (96-106) Bicarb 25
Given this presentation and the labs (low anion gap and elevated calcium anemia kidney failure) what will you think of What will you order next
Serum and urine protein electrophoresis
Intratubular refractile casts with surrounding syncytial giant cell reaction with chronic tubulointerstitial nephritis and fibrosis characteristic of myeloma cast nephropathy
Kidney Biopsy
CASE STUDYbull A 35 year old African American woman was seen in the clinic for
chronic cough and dyspnea on exertion She gave history of vague symptoms of fatigue and weight loss of 20 Ibs over the last six months
bull List some differentialsbull TB sarcoid lupus thyroid problems PEbull What would you orderbull PPD cbc cmp UA TSH ANA pa and lat cxr
bull Her labs were significant for mildly elevated calcium level and a creatinine of 20 mgdL eGFR 37
bull She had 750 mg of proteinuriaday
bull PPD neg ANA neg TSH and other labs WNL
bull Assuming this is present more than 3 monthshelliphellipwhat is her ckd stage
bull G3b A3
bull What do we still need
CT scan of chest
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileAnterior_mediastinal_mass_thymomajpgCreative Commons License associated httpcreativecommonsorglicensesby20deeden
CXR ndash HILAR LYMPHADENOPATHY
WHATS NEEDED NEXT
bull Biopsy of hilar lymphadenopathy or renal biopsy
bull DX sarcoidosis
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileSarcoidosis_signs_and_symptomsjpgThis work is in the public domain in the United States because it is a work of the United States Federal Government under the terms of Title 17 Chapter 1 Section 105 of the US Code
NEWLY DX CKD
bull 1) urinalysis microscopy ultrasound proteincr ratio
bull If obstruction-treat
bull No obstruction
bull Hx critical (consider myeloma if high risk)
bull glomerular bleeding or albumin in urine
bull Yes workup for glomerular causes (ANArf hep B C upep spep ANCA complement C3 C4)
bull No sterile pyruria-consider interstitial nephritis
bull High risk renovascular disease Evaluate renovascular disease
Additional Online Resources for CKD LearningbullNational Kidney Foundation wwwkidneyorgbullUnited States Renal Data Service wwwusrdsorgbullCDCrsquos CKD Surveillance Project
httpnccdcdcgovckdbullNational Kidney Disease Education Program
(NKDEP) httpnkdepnihgov
BIBLIOGRAPHY
bull Afzali B amp Goldsmith D J (2016 June 29) Statins and chronic kidney disease (G C Curhan amp A M Sheridan Eds) Retrieved 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsstatins-and-chronic-kidney-disease
bull American Diabetes Association Standards of Medical Care in Diabetes (2017) Microvascular complications and foot care Diabetes Care 2017 (40) S88-S98
bull American Diabetes Association Standards of Medical Care in Diabetes (2017) Microvascular complications and foot care Diabetes Care 40 (suppl 1) S88-S98
bull Berns J S (2017 Mar 22) Treatment of anemia in nondialysis chronic kidney disease (T A Golper amp A M Sheridan Eds) Retrieved from UpToDate httpswww-uptodate-comproxywichitaeducontentstreatment-of-anemia-in-nondialysis-chronic-kidney-disease
bull Chan M Dall A T Fletcher K E Lu N amp Trivedi H (2007) Outcomes in patients with chronic kidney disease referred late to nephrologists a meta-analysis American Journal of Medicine 120(12) 1063-1070
bull Coresh J Selvin E amp Stevens L A (2007) Prevalence of chronic kidny disease in the United States JAMA 298(17) doi101001jama298172038
bull de Brito-Ashurst I Varagunam M Raftery M amp Yagoob M (2009) Bicarbonate supplementation slows progression of CKD and improves nutritional status Journal of American Society of Nephrology (20) 2075-2084
BIBLIOGRAPHY
bull Duncan L Heathcoat J Djurdjev O amp Levin A (2001) Screening for renal disease using serum creatinine who are we missing Nephrology Dialysis and Transplant 16(5) 1042-1046
bull Dunkler D Gao P Lee S F Heinz G Clase C M Tobe S Oberbauer R (2015 August 7) Risk prediction for early CKD in type 2 diabetes Retrieved from Clinical Journal of the American Society of Nephrology httpcjasnasnjournalsorgcontent1081371fullsid=61422554-a5f1-41ac-b696-dcd3b12bd268
bull Fatehi P amp Chi-yuan H (September 15 2016) Diagnostic approach to the patient with newly identified chronic kidney disease (G C Curhan amp A M Sheridan Eds) Retrieved May 7 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsdiagnostic-approach-to-the-patient-with-newly-identified-chronic-kidney-disease
bull Fink J e (2009) Chronic Kidney Disease as an Under-Recognized Threat to Patient Safety American journal of kidney diseases the official journal of the National Kidney Foundation 53(4) 681-688
bull Gaffo A L amp Saag K G (2008 Nov) Management of hyperuricemia and gout in CKD doihttpdxdoiorg101053jajkd200807035
bull Hebert L A amp Parikh S V (2014 June 18) Differential diagnosis and evaluation of glomerular disease (R J Glassock amp A Q Lam Eds) Retrieved May 7 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsdifferential-diagnosis-and-evaluation-of-glomerular-disease
bull Inker L Perrone R D Sterns R H amp Forman J P (2017 March 7) Assessment of kidney function Retrieved from UpToDate httpswww-uptodate-comproxywichitaeducontentsassessment-of-kidney-functionsource=search_resultampsearch=creatinineampselectedTitle=1~150
BIBLIOGRAPHY
bull James P A Ortiz E amp Et Al (2014) Evidence based guideline for the management of high blood pressure in adults (JNC) JAMA 311(5) 507-520
bull Kidney Disease Improving Global Outcomes (KDIGO) CKD Work Group (2013 January) KDIGO 2012 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease Retrieved from Kidney International Supplement httpwwwkidney-internationalorg
bull Kunz R Friedrich C Wolbers M amp Mann J F (2008) Meta-analysis effect of monotherapy and combination therapy with inhibitors of the renin angiotensin system on proteinuria in renal disease Annals of Internal Medicine 148(1) 30-48
bull Levey A Stevens L A Schmid C H Castro A F Feldman H I Kusek J W Coresh J (2009) A new equation to estimate glomerular filtration rate Annals of Internal Medicine 150(9) 604-612
bull Levin A Bakris G L Molitch M Smulders M M Williams L A amp Andress D L (2007 Jan) Prevalence of abnormal serum vitamin D PTH calcium and phosphorus in patients with chronic kidney disease results of the study to evaluate early kidney disease Kidney International 71(1) 31-38 Retrieved from PubMED
bull Mahajan A Simoni J Sheather S Broglio K Rajab M amp Wesson D (2010) Daily oral sodium bicarbonate preserves glomerular filtration rate by slowing its decline in early hypertensive nephropathy Kidney International (78_ 303-309
bull Mann J Schmieder R E amp McQueen M (2008) Renal outcomes with telmisartan ramipril or both in people at high vascular risk (the ONTARGET study) a multicentre randomised doubleblind ocntrolled trial Lancet 372(9638) 547-533
BIBLIOGRAPHY
bull Matovinović M S (2009) Pathophysiology and classification of kidney disease Retrieved from The Journal of the International Federation of Clinical Chemistry and Laboratory Medicine httpwwwifccorgifccfilesdocs20010902pdf
bull Moe S Drueke T Lameire N amp Eknoyan G (2007 Jan) Chronic kidney disease-mineral-bone disorder a new paradigmdoi101053jackd200610005
bull Murtagh F E Marsh J E Donohoe P Ekbal N J Sheerin N S amp Harris F E (2007 July) Dialysis or not A comparative survival study of patients over 75 years with chronic kidney disease stage 5 Retrieved from Nephrology Dialysis and Transplant 22(7) httpswwwncbinlmnihgovpubmed17412702
bull National Kidney Foundation (2002) KDOQI clinical practice guidelines for chronic kidney disease evaluation classification andstratification American Journal of Kidney Disease S1-S266
bull National Kidney Foundation (2014 November 5) Fact Sheets Retrieved from httpwwwkidneyorgnewsnewsroomfactsheetsFastFacts
bull Pal S (2012 June 2) Trends in chronic kidney disease Retrieved from US Pharmacist (37)6 httpswwwuspharmacistcomarticletrends-in-chronic-kidney-disease
bull Qunibi W amp Henrich W L (2017 Jan 19) Overview of chronic kidney disease-mineral and bone disorder (J Berns amp A M Sheridan Eds) Retrieved from UpToDate httpswww-uptodate-comoverview-of-chronic-kidney-disease-mineral-and-bone-disorder-ckd-mbd
bull Rosenberg M (2016 Feb 24) Overview of the management of chronic kidney disease in adults (G C Curhan amp A M Sheridan Eds) Retrieved from UpToDate UpToDate httpswww-uptodate-comproxywichitaeducontentsoverview-of-the-management-of-chronic-kidney-disease-in-adults
BIBLIOGRAPHY
bull Szczech L Stewart R C Hsu-Lin S DeLosky R J Astor B C Fox C H Vassalotti J A (2014) Primary care detection of chronic kidney disease in adults with type 2 diabetes The ADD-CKD Study (Awareness Detection and Drug Therapy in type 2 diabetes and chronic kidney disease PLOS doihttpsdoiorg101371journalpone0110535
bull USRDS (2016) Annual data report 2016 Epidemiology of kidney disease in the United States Retrieved from United States Renal Data System httpswwwusrdsorgadraspx
bull Vasudev B amp Vasudev M (2012) A model curriculum for residents rotating in nephrology MedEDPORTAL doihttpdoiorg1015766mep_2374-82658288
bull Wei L MacDonald T M Jennings C Sheng X amp Flynn R W (2013) Estimated GFR reporting is associated with decreased nonsteroidal anti-inflammatory drug prescribing and increased renal function Kidney International (84)1 174-178
chronic kidney disease in primary care
CKD as a Public Health Issue
Slide Number 3
Costs of CKD in 2013 dollarsUSRDS report
Steps to CKD Patient Care
Renal anatomy and physiology
Definition of Chronic Kidney Disease
CKD Risk Factors
Gaps in CKD Diagnosis
Slide Number 10
Steps to CKD Patient Care
creatinine
Glomerular filtration rate
Slide Number 14
Slide Number 15
Use These Equations Cautiously if at all in hellip
lab albumin creatinine ratio
The New CKD Categories
Steps to CKD Patient Care
Slide Number 20
Kidney Involvement in Systemic Diseases
Slide Number 22
Slide Number 23
DysmorphicRenal Hematuria
Slide Number 25
If you have albuminuria or hematuria-order the following labs
Prevalence of Abnormalities of Mineral Metabolism PTH in CKD
Managing CKD-MBD complications
CKD-MBD Testing
Anemia Becomes More Common as Kidney Function Declines
Detect and Manage CKD Complications
Complications-metabolic acidosis
Complications-vascular calcification
Hyperkalemia management
Hyperuricemia levels amp CKD
CKD monitoring levels 345
Slide Number 59
When to Refer to a Nephrologist
When to Refer
Steps to CKD Patient Care
Kidney transplantation
Starting Dialysis in the ElderlyhellipOr Not
Ckd management
Case 1
Slide Number 67
Lab results
Slide Number 69
Hypertensive nephropathy with proteinuria
Slide Number 71
Case 2
Slide Number 73
Management of CKD in Diabetes
Case 3
Case 3
Systemic Lupus Erythematosus (SLE)
SLE ndash Lupus Nephritis
Case 5
Case 5
Slide Number 81
Slide Number 82
Case study
Slide Number 84
CXR ndash Hilar Lymphadenopathy
Whats needed next
Slide Number 87
newly dx ckd
Slide Number 89
Bibliography
bibliography
bibliography
bibliography
bibliography
SLE ndash LUPUS NEPHRITIS
bull Race SLE is more commonsevere in African americans than Caucasiansbull
bull Gender female-to-male ratio of 91
bull Age Most patients develop lupus nephritis early in their disease course SLE is more common among women in the third decade of life and lupus nephritis occurs in patients aged 20-40 years
bull Kidney Biopsy For staging lupus nephritis (Class 1-5)
CASE 5bull A 80 year old man who has not seen a PCP in many years
presents to your clinic for weakness for the past few months On further questioning he tells you that his bones also have been hurting lately and he has developed leg swelling in the past month or so
bull On exam bull BP 16090 P 88 Afebrilebull GEN Thin built manbull HEENT pallor presentbull Lungs clearbull CVS S1S2 regular no rub or gallopbull Abdomen soft NTbull Ext 2 + edema
CASE 5
bull Differentials
bull CHF MI Cancer arthritis
bull Labs
bull CBC CMP urine microscopy urine proteincr ratio ESR TSH EKG BNP pa and lat CXR
bull LABS Urine dipstick negative for protein or blood
bull Basic chem bull Na 136 (135-145) K 51 (35-55) Chloride 108 (96-106) Bicarb 25
Given this presentation and the labs (low anion gap and elevated calcium anemia kidney failure) what will you think of What will you order next
Serum and urine protein electrophoresis
Intratubular refractile casts with surrounding syncytial giant cell reaction with chronic tubulointerstitial nephritis and fibrosis characteristic of myeloma cast nephropathy
Kidney Biopsy
CASE STUDYbull A 35 year old African American woman was seen in the clinic for
chronic cough and dyspnea on exertion She gave history of vague symptoms of fatigue and weight loss of 20 Ibs over the last six months
bull List some differentialsbull TB sarcoid lupus thyroid problems PEbull What would you orderbull PPD cbc cmp UA TSH ANA pa and lat cxr
bull Her labs were significant for mildly elevated calcium level and a creatinine of 20 mgdL eGFR 37
bull She had 750 mg of proteinuriaday
bull PPD neg ANA neg TSH and other labs WNL
bull Assuming this is present more than 3 monthshelliphellipwhat is her ckd stage
bull G3b A3
bull What do we still need
CT scan of chest
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileAnterior_mediastinal_mass_thymomajpgCreative Commons License associated httpcreativecommonsorglicensesby20deeden
CXR ndash HILAR LYMPHADENOPATHY
WHATS NEEDED NEXT
bull Biopsy of hilar lymphadenopathy or renal biopsy
bull DX sarcoidosis
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileSarcoidosis_signs_and_symptomsjpgThis work is in the public domain in the United States because it is a work of the United States Federal Government under the terms of Title 17 Chapter 1 Section 105 of the US Code
NEWLY DX CKD
bull 1) urinalysis microscopy ultrasound proteincr ratio
bull If obstruction-treat
bull No obstruction
bull Hx critical (consider myeloma if high risk)
bull glomerular bleeding or albumin in urine
bull Yes workup for glomerular causes (ANArf hep B C upep spep ANCA complement C3 C4)
bull No sterile pyruria-consider interstitial nephritis
bull High risk renovascular disease Evaluate renovascular disease
Additional Online Resources for CKD LearningbullNational Kidney Foundation wwwkidneyorgbullUnited States Renal Data Service wwwusrdsorgbullCDCrsquos CKD Surveillance Project
httpnccdcdcgovckdbullNational Kidney Disease Education Program
(NKDEP) httpnkdepnihgov
BIBLIOGRAPHY
bull Afzali B amp Goldsmith D J (2016 June 29) Statins and chronic kidney disease (G C Curhan amp A M Sheridan Eds) Retrieved 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsstatins-and-chronic-kidney-disease
bull American Diabetes Association Standards of Medical Care in Diabetes (2017) Microvascular complications and foot care Diabetes Care 2017 (40) S88-S98
bull American Diabetes Association Standards of Medical Care in Diabetes (2017) Microvascular complications and foot care Diabetes Care 40 (suppl 1) S88-S98
bull Berns J S (2017 Mar 22) Treatment of anemia in nondialysis chronic kidney disease (T A Golper amp A M Sheridan Eds) Retrieved from UpToDate httpswww-uptodate-comproxywichitaeducontentstreatment-of-anemia-in-nondialysis-chronic-kidney-disease
bull Chan M Dall A T Fletcher K E Lu N amp Trivedi H (2007) Outcomes in patients with chronic kidney disease referred late to nephrologists a meta-analysis American Journal of Medicine 120(12) 1063-1070
bull Coresh J Selvin E amp Stevens L A (2007) Prevalence of chronic kidny disease in the United States JAMA 298(17) doi101001jama298172038
bull de Brito-Ashurst I Varagunam M Raftery M amp Yagoob M (2009) Bicarbonate supplementation slows progression of CKD and improves nutritional status Journal of American Society of Nephrology (20) 2075-2084
BIBLIOGRAPHY
bull Duncan L Heathcoat J Djurdjev O amp Levin A (2001) Screening for renal disease using serum creatinine who are we missing Nephrology Dialysis and Transplant 16(5) 1042-1046
bull Dunkler D Gao P Lee S F Heinz G Clase C M Tobe S Oberbauer R (2015 August 7) Risk prediction for early CKD in type 2 diabetes Retrieved from Clinical Journal of the American Society of Nephrology httpcjasnasnjournalsorgcontent1081371fullsid=61422554-a5f1-41ac-b696-dcd3b12bd268
bull Fatehi P amp Chi-yuan H (September 15 2016) Diagnostic approach to the patient with newly identified chronic kidney disease (G C Curhan amp A M Sheridan Eds) Retrieved May 7 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsdiagnostic-approach-to-the-patient-with-newly-identified-chronic-kidney-disease
bull Fink J e (2009) Chronic Kidney Disease as an Under-Recognized Threat to Patient Safety American journal of kidney diseases the official journal of the National Kidney Foundation 53(4) 681-688
bull Gaffo A L amp Saag K G (2008 Nov) Management of hyperuricemia and gout in CKD doihttpdxdoiorg101053jajkd200807035
bull Hebert L A amp Parikh S V (2014 June 18) Differential diagnosis and evaluation of glomerular disease (R J Glassock amp A Q Lam Eds) Retrieved May 7 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsdifferential-diagnosis-and-evaluation-of-glomerular-disease
bull Inker L Perrone R D Sterns R H amp Forman J P (2017 March 7) Assessment of kidney function Retrieved from UpToDate httpswww-uptodate-comproxywichitaeducontentsassessment-of-kidney-functionsource=search_resultampsearch=creatinineampselectedTitle=1~150
BIBLIOGRAPHY
bull James P A Ortiz E amp Et Al (2014) Evidence based guideline for the management of high blood pressure in adults (JNC) JAMA 311(5) 507-520
bull Kidney Disease Improving Global Outcomes (KDIGO) CKD Work Group (2013 January) KDIGO 2012 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease Retrieved from Kidney International Supplement httpwwwkidney-internationalorg
bull Kunz R Friedrich C Wolbers M amp Mann J F (2008) Meta-analysis effect of monotherapy and combination therapy with inhibitors of the renin angiotensin system on proteinuria in renal disease Annals of Internal Medicine 148(1) 30-48
bull Levey A Stevens L A Schmid C H Castro A F Feldman H I Kusek J W Coresh J (2009) A new equation to estimate glomerular filtration rate Annals of Internal Medicine 150(9) 604-612
bull Levin A Bakris G L Molitch M Smulders M M Williams L A amp Andress D L (2007 Jan) Prevalence of abnormal serum vitamin D PTH calcium and phosphorus in patients with chronic kidney disease results of the study to evaluate early kidney disease Kidney International 71(1) 31-38 Retrieved from PubMED
bull Mahajan A Simoni J Sheather S Broglio K Rajab M amp Wesson D (2010) Daily oral sodium bicarbonate preserves glomerular filtration rate by slowing its decline in early hypertensive nephropathy Kidney International (78_ 303-309
bull Mann J Schmieder R E amp McQueen M (2008) Renal outcomes with telmisartan ramipril or both in people at high vascular risk (the ONTARGET study) a multicentre randomised doubleblind ocntrolled trial Lancet 372(9638) 547-533
BIBLIOGRAPHY
bull Matovinović M S (2009) Pathophysiology and classification of kidney disease Retrieved from The Journal of the International Federation of Clinical Chemistry and Laboratory Medicine httpwwwifccorgifccfilesdocs20010902pdf
bull Moe S Drueke T Lameire N amp Eknoyan G (2007 Jan) Chronic kidney disease-mineral-bone disorder a new paradigmdoi101053jackd200610005
bull Murtagh F E Marsh J E Donohoe P Ekbal N J Sheerin N S amp Harris F E (2007 July) Dialysis or not A comparative survival study of patients over 75 years with chronic kidney disease stage 5 Retrieved from Nephrology Dialysis and Transplant 22(7) httpswwwncbinlmnihgovpubmed17412702
bull National Kidney Foundation (2002) KDOQI clinical practice guidelines for chronic kidney disease evaluation classification andstratification American Journal of Kidney Disease S1-S266
bull National Kidney Foundation (2014 November 5) Fact Sheets Retrieved from httpwwwkidneyorgnewsnewsroomfactsheetsFastFacts
bull Pal S (2012 June 2) Trends in chronic kidney disease Retrieved from US Pharmacist (37)6 httpswwwuspharmacistcomarticletrends-in-chronic-kidney-disease
bull Qunibi W amp Henrich W L (2017 Jan 19) Overview of chronic kidney disease-mineral and bone disorder (J Berns amp A M Sheridan Eds) Retrieved from UpToDate httpswww-uptodate-comoverview-of-chronic-kidney-disease-mineral-and-bone-disorder-ckd-mbd
bull Rosenberg M (2016 Feb 24) Overview of the management of chronic kidney disease in adults (G C Curhan amp A M Sheridan Eds) Retrieved from UpToDate UpToDate httpswww-uptodate-comproxywichitaeducontentsoverview-of-the-management-of-chronic-kidney-disease-in-adults
BIBLIOGRAPHY
bull Szczech L Stewart R C Hsu-Lin S DeLosky R J Astor B C Fox C H Vassalotti J A (2014) Primary care detection of chronic kidney disease in adults with type 2 diabetes The ADD-CKD Study (Awareness Detection and Drug Therapy in type 2 diabetes and chronic kidney disease PLOS doihttpsdoiorg101371journalpone0110535
bull USRDS (2016) Annual data report 2016 Epidemiology of kidney disease in the United States Retrieved from United States Renal Data System httpswwwusrdsorgadraspx
bull Vasudev B amp Vasudev M (2012) A model curriculum for residents rotating in nephrology MedEDPORTAL doihttpdoiorg1015766mep_2374-82658288
bull Wei L MacDonald T M Jennings C Sheng X amp Flynn R W (2013) Estimated GFR reporting is associated with decreased nonsteroidal anti-inflammatory drug prescribing and increased renal function Kidney International (84)1 174-178
chronic kidney disease in primary care
CKD as a Public Health Issue
Slide Number 3
Costs of CKD in 2013 dollarsUSRDS report
Steps to CKD Patient Care
Renal anatomy and physiology
Definition of Chronic Kidney Disease
CKD Risk Factors
Gaps in CKD Diagnosis
Slide Number 10
Steps to CKD Patient Care
creatinine
Glomerular filtration rate
Slide Number 14
Slide Number 15
Use These Equations Cautiously if at all in hellip
lab albumin creatinine ratio
The New CKD Categories
Steps to CKD Patient Care
Slide Number 20
Kidney Involvement in Systemic Diseases
Slide Number 22
Slide Number 23
DysmorphicRenal Hematuria
Slide Number 25
If you have albuminuria or hematuria-order the following labs
Prevalence of Abnormalities of Mineral Metabolism PTH in CKD
Managing CKD-MBD complications
CKD-MBD Testing
Anemia Becomes More Common as Kidney Function Declines
Detect and Manage CKD Complications
Complications-metabolic acidosis
Complications-vascular calcification
Hyperkalemia management
Hyperuricemia levels amp CKD
CKD monitoring levels 345
Slide Number 59
When to Refer to a Nephrologist
When to Refer
Steps to CKD Patient Care
Kidney transplantation
Starting Dialysis in the ElderlyhellipOr Not
Ckd management
Case 1
Slide Number 67
Lab results
Slide Number 69
Hypertensive nephropathy with proteinuria
Slide Number 71
Case 2
Slide Number 73
Management of CKD in Diabetes
Case 3
Case 3
Systemic Lupus Erythematosus (SLE)
SLE ndash Lupus Nephritis
Case 5
Case 5
Slide Number 81
Slide Number 82
Case study
Slide Number 84
CXR ndash Hilar Lymphadenopathy
Whats needed next
Slide Number 87
newly dx ckd
Slide Number 89
Bibliography
bibliography
bibliography
bibliography
bibliography
CASE 5bull A 80 year old man who has not seen a PCP in many years
presents to your clinic for weakness for the past few months On further questioning he tells you that his bones also have been hurting lately and he has developed leg swelling in the past month or so
bull On exam bull BP 16090 P 88 Afebrilebull GEN Thin built manbull HEENT pallor presentbull Lungs clearbull CVS S1S2 regular no rub or gallopbull Abdomen soft NTbull Ext 2 + edema
CASE 5
bull Differentials
bull CHF MI Cancer arthritis
bull Labs
bull CBC CMP urine microscopy urine proteincr ratio ESR TSH EKG BNP pa and lat CXR
bull LABS Urine dipstick negative for protein or blood
bull Basic chem bull Na 136 (135-145) K 51 (35-55) Chloride 108 (96-106) Bicarb 25
Given this presentation and the labs (low anion gap and elevated calcium anemia kidney failure) what will you think of What will you order next
Serum and urine protein electrophoresis
Intratubular refractile casts with surrounding syncytial giant cell reaction with chronic tubulointerstitial nephritis and fibrosis characteristic of myeloma cast nephropathy
Kidney Biopsy
CASE STUDYbull A 35 year old African American woman was seen in the clinic for
chronic cough and dyspnea on exertion She gave history of vague symptoms of fatigue and weight loss of 20 Ibs over the last six months
bull List some differentialsbull TB sarcoid lupus thyroid problems PEbull What would you orderbull PPD cbc cmp UA TSH ANA pa and lat cxr
bull Her labs were significant for mildly elevated calcium level and a creatinine of 20 mgdL eGFR 37
bull She had 750 mg of proteinuriaday
bull PPD neg ANA neg TSH and other labs WNL
bull Assuming this is present more than 3 monthshelliphellipwhat is her ckd stage
bull G3b A3
bull What do we still need
CT scan of chest
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileAnterior_mediastinal_mass_thymomajpgCreative Commons License associated httpcreativecommonsorglicensesby20deeden
CXR ndash HILAR LYMPHADENOPATHY
WHATS NEEDED NEXT
bull Biopsy of hilar lymphadenopathy or renal biopsy
bull DX sarcoidosis
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileSarcoidosis_signs_and_symptomsjpgThis work is in the public domain in the United States because it is a work of the United States Federal Government under the terms of Title 17 Chapter 1 Section 105 of the US Code
NEWLY DX CKD
bull 1) urinalysis microscopy ultrasound proteincr ratio
bull If obstruction-treat
bull No obstruction
bull Hx critical (consider myeloma if high risk)
bull glomerular bleeding or albumin in urine
bull Yes workup for glomerular causes (ANArf hep B C upep spep ANCA complement C3 C4)
bull No sterile pyruria-consider interstitial nephritis
bull High risk renovascular disease Evaluate renovascular disease
Additional Online Resources for CKD LearningbullNational Kidney Foundation wwwkidneyorgbullUnited States Renal Data Service wwwusrdsorgbullCDCrsquos CKD Surveillance Project
httpnccdcdcgovckdbullNational Kidney Disease Education Program
(NKDEP) httpnkdepnihgov
BIBLIOGRAPHY
bull Afzali B amp Goldsmith D J (2016 June 29) Statins and chronic kidney disease (G C Curhan amp A M Sheridan Eds) Retrieved 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsstatins-and-chronic-kidney-disease
bull American Diabetes Association Standards of Medical Care in Diabetes (2017) Microvascular complications and foot care Diabetes Care 2017 (40) S88-S98
bull American Diabetes Association Standards of Medical Care in Diabetes (2017) Microvascular complications and foot care Diabetes Care 40 (suppl 1) S88-S98
bull Berns J S (2017 Mar 22) Treatment of anemia in nondialysis chronic kidney disease (T A Golper amp A M Sheridan Eds) Retrieved from UpToDate httpswww-uptodate-comproxywichitaeducontentstreatment-of-anemia-in-nondialysis-chronic-kidney-disease
bull Chan M Dall A T Fletcher K E Lu N amp Trivedi H (2007) Outcomes in patients with chronic kidney disease referred late to nephrologists a meta-analysis American Journal of Medicine 120(12) 1063-1070
bull Coresh J Selvin E amp Stevens L A (2007) Prevalence of chronic kidny disease in the United States JAMA 298(17) doi101001jama298172038
bull de Brito-Ashurst I Varagunam M Raftery M amp Yagoob M (2009) Bicarbonate supplementation slows progression of CKD and improves nutritional status Journal of American Society of Nephrology (20) 2075-2084
BIBLIOGRAPHY
bull Duncan L Heathcoat J Djurdjev O amp Levin A (2001) Screening for renal disease using serum creatinine who are we missing Nephrology Dialysis and Transplant 16(5) 1042-1046
bull Dunkler D Gao P Lee S F Heinz G Clase C M Tobe S Oberbauer R (2015 August 7) Risk prediction for early CKD in type 2 diabetes Retrieved from Clinical Journal of the American Society of Nephrology httpcjasnasnjournalsorgcontent1081371fullsid=61422554-a5f1-41ac-b696-dcd3b12bd268
bull Fatehi P amp Chi-yuan H (September 15 2016) Diagnostic approach to the patient with newly identified chronic kidney disease (G C Curhan amp A M Sheridan Eds) Retrieved May 7 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsdiagnostic-approach-to-the-patient-with-newly-identified-chronic-kidney-disease
bull Fink J e (2009) Chronic Kidney Disease as an Under-Recognized Threat to Patient Safety American journal of kidney diseases the official journal of the National Kidney Foundation 53(4) 681-688
bull Gaffo A L amp Saag K G (2008 Nov) Management of hyperuricemia and gout in CKD doihttpdxdoiorg101053jajkd200807035
bull Hebert L A amp Parikh S V (2014 June 18) Differential diagnosis and evaluation of glomerular disease (R J Glassock amp A Q Lam Eds) Retrieved May 7 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsdifferential-diagnosis-and-evaluation-of-glomerular-disease
bull Inker L Perrone R D Sterns R H amp Forman J P (2017 March 7) Assessment of kidney function Retrieved from UpToDate httpswww-uptodate-comproxywichitaeducontentsassessment-of-kidney-functionsource=search_resultampsearch=creatinineampselectedTitle=1~150
BIBLIOGRAPHY
bull James P A Ortiz E amp Et Al (2014) Evidence based guideline for the management of high blood pressure in adults (JNC) JAMA 311(5) 507-520
bull Kidney Disease Improving Global Outcomes (KDIGO) CKD Work Group (2013 January) KDIGO 2012 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease Retrieved from Kidney International Supplement httpwwwkidney-internationalorg
bull Kunz R Friedrich C Wolbers M amp Mann J F (2008) Meta-analysis effect of monotherapy and combination therapy with inhibitors of the renin angiotensin system on proteinuria in renal disease Annals of Internal Medicine 148(1) 30-48
bull Levey A Stevens L A Schmid C H Castro A F Feldman H I Kusek J W Coresh J (2009) A new equation to estimate glomerular filtration rate Annals of Internal Medicine 150(9) 604-612
bull Levin A Bakris G L Molitch M Smulders M M Williams L A amp Andress D L (2007 Jan) Prevalence of abnormal serum vitamin D PTH calcium and phosphorus in patients with chronic kidney disease results of the study to evaluate early kidney disease Kidney International 71(1) 31-38 Retrieved from PubMED
bull Mahajan A Simoni J Sheather S Broglio K Rajab M amp Wesson D (2010) Daily oral sodium bicarbonate preserves glomerular filtration rate by slowing its decline in early hypertensive nephropathy Kidney International (78_ 303-309
bull Mann J Schmieder R E amp McQueen M (2008) Renal outcomes with telmisartan ramipril or both in people at high vascular risk (the ONTARGET study) a multicentre randomised doubleblind ocntrolled trial Lancet 372(9638) 547-533
BIBLIOGRAPHY
bull Matovinović M S (2009) Pathophysiology and classification of kidney disease Retrieved from The Journal of the International Federation of Clinical Chemistry and Laboratory Medicine httpwwwifccorgifccfilesdocs20010902pdf
bull Moe S Drueke T Lameire N amp Eknoyan G (2007 Jan) Chronic kidney disease-mineral-bone disorder a new paradigmdoi101053jackd200610005
bull Murtagh F E Marsh J E Donohoe P Ekbal N J Sheerin N S amp Harris F E (2007 July) Dialysis or not A comparative survival study of patients over 75 years with chronic kidney disease stage 5 Retrieved from Nephrology Dialysis and Transplant 22(7) httpswwwncbinlmnihgovpubmed17412702
bull National Kidney Foundation (2002) KDOQI clinical practice guidelines for chronic kidney disease evaluation classification andstratification American Journal of Kidney Disease S1-S266
bull National Kidney Foundation (2014 November 5) Fact Sheets Retrieved from httpwwwkidneyorgnewsnewsroomfactsheetsFastFacts
bull Pal S (2012 June 2) Trends in chronic kidney disease Retrieved from US Pharmacist (37)6 httpswwwuspharmacistcomarticletrends-in-chronic-kidney-disease
bull Qunibi W amp Henrich W L (2017 Jan 19) Overview of chronic kidney disease-mineral and bone disorder (J Berns amp A M Sheridan Eds) Retrieved from UpToDate httpswww-uptodate-comoverview-of-chronic-kidney-disease-mineral-and-bone-disorder-ckd-mbd
bull Rosenberg M (2016 Feb 24) Overview of the management of chronic kidney disease in adults (G C Curhan amp A M Sheridan Eds) Retrieved from UpToDate UpToDate httpswww-uptodate-comproxywichitaeducontentsoverview-of-the-management-of-chronic-kidney-disease-in-adults
BIBLIOGRAPHY
bull Szczech L Stewart R C Hsu-Lin S DeLosky R J Astor B C Fox C H Vassalotti J A (2014) Primary care detection of chronic kidney disease in adults with type 2 diabetes The ADD-CKD Study (Awareness Detection and Drug Therapy in type 2 diabetes and chronic kidney disease PLOS doihttpsdoiorg101371journalpone0110535
bull USRDS (2016) Annual data report 2016 Epidemiology of kidney disease in the United States Retrieved from United States Renal Data System httpswwwusrdsorgadraspx
bull Vasudev B amp Vasudev M (2012) A model curriculum for residents rotating in nephrology MedEDPORTAL doihttpdoiorg1015766mep_2374-82658288
bull Wei L MacDonald T M Jennings C Sheng X amp Flynn R W (2013) Estimated GFR reporting is associated with decreased nonsteroidal anti-inflammatory drug prescribing and increased renal function Kidney International (84)1 174-178
chronic kidney disease in primary care
CKD as a Public Health Issue
Slide Number 3
Costs of CKD in 2013 dollarsUSRDS report
Steps to CKD Patient Care
Renal anatomy and physiology
Definition of Chronic Kidney Disease
CKD Risk Factors
Gaps in CKD Diagnosis
Slide Number 10
Steps to CKD Patient Care
creatinine
Glomerular filtration rate
Slide Number 14
Slide Number 15
Use These Equations Cautiously if at all in hellip
lab albumin creatinine ratio
The New CKD Categories
Steps to CKD Patient Care
Slide Number 20
Kidney Involvement in Systemic Diseases
Slide Number 22
Slide Number 23
DysmorphicRenal Hematuria
Slide Number 25
If you have albuminuria or hematuria-order the following labs
Given this presentation and the labs (low anion gap and elevated calcium anemia kidney failure) what will you think of What will you order next
Serum and urine protein electrophoresis
Intratubular refractile casts with surrounding syncytial giant cell reaction with chronic tubulointerstitial nephritis and fibrosis characteristic of myeloma cast nephropathy
Kidney Biopsy
CASE STUDYbull A 35 year old African American woman was seen in the clinic for
chronic cough and dyspnea on exertion She gave history of vague symptoms of fatigue and weight loss of 20 Ibs over the last six months
bull List some differentialsbull TB sarcoid lupus thyroid problems PEbull What would you orderbull PPD cbc cmp UA TSH ANA pa and lat cxr
bull Her labs were significant for mildly elevated calcium level and a creatinine of 20 mgdL eGFR 37
bull She had 750 mg of proteinuriaday
bull PPD neg ANA neg TSH and other labs WNL
bull Assuming this is present more than 3 monthshelliphellipwhat is her ckd stage
bull G3b A3
bull What do we still need
CT scan of chest
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileAnterior_mediastinal_mass_thymomajpgCreative Commons License associated httpcreativecommonsorglicensesby20deeden
CXR ndash HILAR LYMPHADENOPATHY
WHATS NEEDED NEXT
bull Biopsy of hilar lymphadenopathy or renal biopsy
bull DX sarcoidosis
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileSarcoidosis_signs_and_symptomsjpgThis work is in the public domain in the United States because it is a work of the United States Federal Government under the terms of Title 17 Chapter 1 Section 105 of the US Code
NEWLY DX CKD
bull 1) urinalysis microscopy ultrasound proteincr ratio
bull If obstruction-treat
bull No obstruction
bull Hx critical (consider myeloma if high risk)
bull glomerular bleeding or albumin in urine
bull Yes workup for glomerular causes (ANArf hep B C upep spep ANCA complement C3 C4)
bull No sterile pyruria-consider interstitial nephritis
bull High risk renovascular disease Evaluate renovascular disease
Additional Online Resources for CKD LearningbullNational Kidney Foundation wwwkidneyorgbullUnited States Renal Data Service wwwusrdsorgbullCDCrsquos CKD Surveillance Project
httpnccdcdcgovckdbullNational Kidney Disease Education Program
(NKDEP) httpnkdepnihgov
BIBLIOGRAPHY
bull Afzali B amp Goldsmith D J (2016 June 29) Statins and chronic kidney disease (G C Curhan amp A M Sheridan Eds) Retrieved 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsstatins-and-chronic-kidney-disease
bull American Diabetes Association Standards of Medical Care in Diabetes (2017) Microvascular complications and foot care Diabetes Care 2017 (40) S88-S98
bull American Diabetes Association Standards of Medical Care in Diabetes (2017) Microvascular complications and foot care Diabetes Care 40 (suppl 1) S88-S98
bull Berns J S (2017 Mar 22) Treatment of anemia in nondialysis chronic kidney disease (T A Golper amp A M Sheridan Eds) Retrieved from UpToDate httpswww-uptodate-comproxywichitaeducontentstreatment-of-anemia-in-nondialysis-chronic-kidney-disease
bull Chan M Dall A T Fletcher K E Lu N amp Trivedi H (2007) Outcomes in patients with chronic kidney disease referred late to nephrologists a meta-analysis American Journal of Medicine 120(12) 1063-1070
bull Coresh J Selvin E amp Stevens L A (2007) Prevalence of chronic kidny disease in the United States JAMA 298(17) doi101001jama298172038
bull de Brito-Ashurst I Varagunam M Raftery M amp Yagoob M (2009) Bicarbonate supplementation slows progression of CKD and improves nutritional status Journal of American Society of Nephrology (20) 2075-2084
BIBLIOGRAPHY
bull Duncan L Heathcoat J Djurdjev O amp Levin A (2001) Screening for renal disease using serum creatinine who are we missing Nephrology Dialysis and Transplant 16(5) 1042-1046
bull Dunkler D Gao P Lee S F Heinz G Clase C M Tobe S Oberbauer R (2015 August 7) Risk prediction for early CKD in type 2 diabetes Retrieved from Clinical Journal of the American Society of Nephrology httpcjasnasnjournalsorgcontent1081371fullsid=61422554-a5f1-41ac-b696-dcd3b12bd268
bull Fatehi P amp Chi-yuan H (September 15 2016) Diagnostic approach to the patient with newly identified chronic kidney disease (G C Curhan amp A M Sheridan Eds) Retrieved May 7 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsdiagnostic-approach-to-the-patient-with-newly-identified-chronic-kidney-disease
bull Fink J e (2009) Chronic Kidney Disease as an Under-Recognized Threat to Patient Safety American journal of kidney diseases the official journal of the National Kidney Foundation 53(4) 681-688
bull Gaffo A L amp Saag K G (2008 Nov) Management of hyperuricemia and gout in CKD doihttpdxdoiorg101053jajkd200807035
bull Hebert L A amp Parikh S V (2014 June 18) Differential diagnosis and evaluation of glomerular disease (R J Glassock amp A Q Lam Eds) Retrieved May 7 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsdifferential-diagnosis-and-evaluation-of-glomerular-disease
bull Inker L Perrone R D Sterns R H amp Forman J P (2017 March 7) Assessment of kidney function Retrieved from UpToDate httpswww-uptodate-comproxywichitaeducontentsassessment-of-kidney-functionsource=search_resultampsearch=creatinineampselectedTitle=1~150
BIBLIOGRAPHY
bull James P A Ortiz E amp Et Al (2014) Evidence based guideline for the management of high blood pressure in adults (JNC) JAMA 311(5) 507-520
bull Kidney Disease Improving Global Outcomes (KDIGO) CKD Work Group (2013 January) KDIGO 2012 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease Retrieved from Kidney International Supplement httpwwwkidney-internationalorg
bull Kunz R Friedrich C Wolbers M amp Mann J F (2008) Meta-analysis effect of monotherapy and combination therapy with inhibitors of the renin angiotensin system on proteinuria in renal disease Annals of Internal Medicine 148(1) 30-48
bull Levey A Stevens L A Schmid C H Castro A F Feldman H I Kusek J W Coresh J (2009) A new equation to estimate glomerular filtration rate Annals of Internal Medicine 150(9) 604-612
bull Levin A Bakris G L Molitch M Smulders M M Williams L A amp Andress D L (2007 Jan) Prevalence of abnormal serum vitamin D PTH calcium and phosphorus in patients with chronic kidney disease results of the study to evaluate early kidney disease Kidney International 71(1) 31-38 Retrieved from PubMED
bull Mahajan A Simoni J Sheather S Broglio K Rajab M amp Wesson D (2010) Daily oral sodium bicarbonate preserves glomerular filtration rate by slowing its decline in early hypertensive nephropathy Kidney International (78_ 303-309
bull Mann J Schmieder R E amp McQueen M (2008) Renal outcomes with telmisartan ramipril or both in people at high vascular risk (the ONTARGET study) a multicentre randomised doubleblind ocntrolled trial Lancet 372(9638) 547-533
BIBLIOGRAPHY
bull Matovinović M S (2009) Pathophysiology and classification of kidney disease Retrieved from The Journal of the International Federation of Clinical Chemistry and Laboratory Medicine httpwwwifccorgifccfilesdocs20010902pdf
bull Moe S Drueke T Lameire N amp Eknoyan G (2007 Jan) Chronic kidney disease-mineral-bone disorder a new paradigmdoi101053jackd200610005
bull Murtagh F E Marsh J E Donohoe P Ekbal N J Sheerin N S amp Harris F E (2007 July) Dialysis or not A comparative survival study of patients over 75 years with chronic kidney disease stage 5 Retrieved from Nephrology Dialysis and Transplant 22(7) httpswwwncbinlmnihgovpubmed17412702
bull National Kidney Foundation (2002) KDOQI clinical practice guidelines for chronic kidney disease evaluation classification andstratification American Journal of Kidney Disease S1-S266
bull National Kidney Foundation (2014 November 5) Fact Sheets Retrieved from httpwwwkidneyorgnewsnewsroomfactsheetsFastFacts
bull Pal S (2012 June 2) Trends in chronic kidney disease Retrieved from US Pharmacist (37)6 httpswwwuspharmacistcomarticletrends-in-chronic-kidney-disease
bull Qunibi W amp Henrich W L (2017 Jan 19) Overview of chronic kidney disease-mineral and bone disorder (J Berns amp A M Sheridan Eds) Retrieved from UpToDate httpswww-uptodate-comoverview-of-chronic-kidney-disease-mineral-and-bone-disorder-ckd-mbd
bull Rosenberg M (2016 Feb 24) Overview of the management of chronic kidney disease in adults (G C Curhan amp A M Sheridan Eds) Retrieved from UpToDate UpToDate httpswww-uptodate-comproxywichitaeducontentsoverview-of-the-management-of-chronic-kidney-disease-in-adults
BIBLIOGRAPHY
bull Szczech L Stewart R C Hsu-Lin S DeLosky R J Astor B C Fox C H Vassalotti J A (2014) Primary care detection of chronic kidney disease in adults with type 2 diabetes The ADD-CKD Study (Awareness Detection and Drug Therapy in type 2 diabetes and chronic kidney disease PLOS doihttpsdoiorg101371journalpone0110535
bull USRDS (2016) Annual data report 2016 Epidemiology of kidney disease in the United States Retrieved from United States Renal Data System httpswwwusrdsorgadraspx
bull Vasudev B amp Vasudev M (2012) A model curriculum for residents rotating in nephrology MedEDPORTAL doihttpdoiorg1015766mep_2374-82658288
bull Wei L MacDonald T M Jennings C Sheng X amp Flynn R W (2013) Estimated GFR reporting is associated with decreased nonsteroidal anti-inflammatory drug prescribing and increased renal function Kidney International (84)1 174-178
chronic kidney disease in primary care
CKD as a Public Health Issue
Slide Number 3
Costs of CKD in 2013 dollarsUSRDS report
Steps to CKD Patient Care
Renal anatomy and physiology
Definition of Chronic Kidney Disease
CKD Risk Factors
Gaps in CKD Diagnosis
Slide Number 10
Steps to CKD Patient Care
creatinine
Glomerular filtration rate
Slide Number 14
Slide Number 15
Use These Equations Cautiously if at all in hellip
lab albumin creatinine ratio
The New CKD Categories
Steps to CKD Patient Care
Slide Number 20
Kidney Involvement in Systemic Diseases
Slide Number 22
Slide Number 23
DysmorphicRenal Hematuria
Slide Number 25
If you have albuminuria or hematuria-order the following labs
Given this presentation and the labs (low anion gap and elevated calcium anemia kidney failure) what will you think of What will you order next
Serum and urine protein electrophoresis
Intratubular refractile casts with surrounding syncytial giant cell reaction with chronic tubulointerstitial nephritis and fibrosis characteristic of myeloma cast nephropathy
Kidney Biopsy
CASE STUDYbull A 35 year old African American woman was seen in the clinic for
chronic cough and dyspnea on exertion She gave history of vague symptoms of fatigue and weight loss of 20 Ibs over the last six months
bull List some differentialsbull TB sarcoid lupus thyroid problems PEbull What would you orderbull PPD cbc cmp UA TSH ANA pa and lat cxr
bull Her labs were significant for mildly elevated calcium level and a creatinine of 20 mgdL eGFR 37
bull She had 750 mg of proteinuriaday
bull PPD neg ANA neg TSH and other labs WNL
bull Assuming this is present more than 3 monthshelliphellipwhat is her ckd stage
bull G3b A3
bull What do we still need
CT scan of chest
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileAnterior_mediastinal_mass_thymomajpgCreative Commons License associated httpcreativecommonsorglicensesby20deeden
CXR ndash HILAR LYMPHADENOPATHY
WHATS NEEDED NEXT
bull Biopsy of hilar lymphadenopathy or renal biopsy
bull DX sarcoidosis
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileSarcoidosis_signs_and_symptomsjpgThis work is in the public domain in the United States because it is a work of the United States Federal Government under the terms of Title 17 Chapter 1 Section 105 of the US Code
NEWLY DX CKD
bull 1) urinalysis microscopy ultrasound proteincr ratio
bull If obstruction-treat
bull No obstruction
bull Hx critical (consider myeloma if high risk)
bull glomerular bleeding or albumin in urine
bull Yes workup for glomerular causes (ANArf hep B C upep spep ANCA complement C3 C4)
bull No sterile pyruria-consider interstitial nephritis
bull High risk renovascular disease Evaluate renovascular disease
Additional Online Resources for CKD LearningbullNational Kidney Foundation wwwkidneyorgbullUnited States Renal Data Service wwwusrdsorgbullCDCrsquos CKD Surveillance Project
httpnccdcdcgovckdbullNational Kidney Disease Education Program
(NKDEP) httpnkdepnihgov
BIBLIOGRAPHY
bull Afzali B amp Goldsmith D J (2016 June 29) Statins and chronic kidney disease (G C Curhan amp A M Sheridan Eds) Retrieved 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsstatins-and-chronic-kidney-disease
bull American Diabetes Association Standards of Medical Care in Diabetes (2017) Microvascular complications and foot care Diabetes Care 2017 (40) S88-S98
bull American Diabetes Association Standards of Medical Care in Diabetes (2017) Microvascular complications and foot care Diabetes Care 40 (suppl 1) S88-S98
bull Berns J S (2017 Mar 22) Treatment of anemia in nondialysis chronic kidney disease (T A Golper amp A M Sheridan Eds) Retrieved from UpToDate httpswww-uptodate-comproxywichitaeducontentstreatment-of-anemia-in-nondialysis-chronic-kidney-disease
bull Chan M Dall A T Fletcher K E Lu N amp Trivedi H (2007) Outcomes in patients with chronic kidney disease referred late to nephrologists a meta-analysis American Journal of Medicine 120(12) 1063-1070
bull Coresh J Selvin E amp Stevens L A (2007) Prevalence of chronic kidny disease in the United States JAMA 298(17) doi101001jama298172038
bull de Brito-Ashurst I Varagunam M Raftery M amp Yagoob M (2009) Bicarbonate supplementation slows progression of CKD and improves nutritional status Journal of American Society of Nephrology (20) 2075-2084
BIBLIOGRAPHY
bull Duncan L Heathcoat J Djurdjev O amp Levin A (2001) Screening for renal disease using serum creatinine who are we missing Nephrology Dialysis and Transplant 16(5) 1042-1046
bull Dunkler D Gao P Lee S F Heinz G Clase C M Tobe S Oberbauer R (2015 August 7) Risk prediction for early CKD in type 2 diabetes Retrieved from Clinical Journal of the American Society of Nephrology httpcjasnasnjournalsorgcontent1081371fullsid=61422554-a5f1-41ac-b696-dcd3b12bd268
bull Fatehi P amp Chi-yuan H (September 15 2016) Diagnostic approach to the patient with newly identified chronic kidney disease (G C Curhan amp A M Sheridan Eds) Retrieved May 7 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsdiagnostic-approach-to-the-patient-with-newly-identified-chronic-kidney-disease
bull Fink J e (2009) Chronic Kidney Disease as an Under-Recognized Threat to Patient Safety American journal of kidney diseases the official journal of the National Kidney Foundation 53(4) 681-688
bull Gaffo A L amp Saag K G (2008 Nov) Management of hyperuricemia and gout in CKD doihttpdxdoiorg101053jajkd200807035
bull Hebert L A amp Parikh S V (2014 June 18) Differential diagnosis and evaluation of glomerular disease (R J Glassock amp A Q Lam Eds) Retrieved May 7 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsdifferential-diagnosis-and-evaluation-of-glomerular-disease
bull Inker L Perrone R D Sterns R H amp Forman J P (2017 March 7) Assessment of kidney function Retrieved from UpToDate httpswww-uptodate-comproxywichitaeducontentsassessment-of-kidney-functionsource=search_resultampsearch=creatinineampselectedTitle=1~150
BIBLIOGRAPHY
bull James P A Ortiz E amp Et Al (2014) Evidence based guideline for the management of high blood pressure in adults (JNC) JAMA 311(5) 507-520
bull Kidney Disease Improving Global Outcomes (KDIGO) CKD Work Group (2013 January) KDIGO 2012 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease Retrieved from Kidney International Supplement httpwwwkidney-internationalorg
bull Kunz R Friedrich C Wolbers M amp Mann J F (2008) Meta-analysis effect of monotherapy and combination therapy with inhibitors of the renin angiotensin system on proteinuria in renal disease Annals of Internal Medicine 148(1) 30-48
bull Levey A Stevens L A Schmid C H Castro A F Feldman H I Kusek J W Coresh J (2009) A new equation to estimate glomerular filtration rate Annals of Internal Medicine 150(9) 604-612
bull Levin A Bakris G L Molitch M Smulders M M Williams L A amp Andress D L (2007 Jan) Prevalence of abnormal serum vitamin D PTH calcium and phosphorus in patients with chronic kidney disease results of the study to evaluate early kidney disease Kidney International 71(1) 31-38 Retrieved from PubMED
bull Mahajan A Simoni J Sheather S Broglio K Rajab M amp Wesson D (2010) Daily oral sodium bicarbonate preserves glomerular filtration rate by slowing its decline in early hypertensive nephropathy Kidney International (78_ 303-309
bull Mann J Schmieder R E amp McQueen M (2008) Renal outcomes with telmisartan ramipril or both in people at high vascular risk (the ONTARGET study) a multicentre randomised doubleblind ocntrolled trial Lancet 372(9638) 547-533
BIBLIOGRAPHY
bull Matovinović M S (2009) Pathophysiology and classification of kidney disease Retrieved from The Journal of the International Federation of Clinical Chemistry and Laboratory Medicine httpwwwifccorgifccfilesdocs20010902pdf
bull Moe S Drueke T Lameire N amp Eknoyan G (2007 Jan) Chronic kidney disease-mineral-bone disorder a new paradigmdoi101053jackd200610005
bull Murtagh F E Marsh J E Donohoe P Ekbal N J Sheerin N S amp Harris F E (2007 July) Dialysis or not A comparative survival study of patients over 75 years with chronic kidney disease stage 5 Retrieved from Nephrology Dialysis and Transplant 22(7) httpswwwncbinlmnihgovpubmed17412702
bull National Kidney Foundation (2002) KDOQI clinical practice guidelines for chronic kidney disease evaluation classification andstratification American Journal of Kidney Disease S1-S266
bull National Kidney Foundation (2014 November 5) Fact Sheets Retrieved from httpwwwkidneyorgnewsnewsroomfactsheetsFastFacts
bull Pal S (2012 June 2) Trends in chronic kidney disease Retrieved from US Pharmacist (37)6 httpswwwuspharmacistcomarticletrends-in-chronic-kidney-disease
bull Qunibi W amp Henrich W L (2017 Jan 19) Overview of chronic kidney disease-mineral and bone disorder (J Berns amp A M Sheridan Eds) Retrieved from UpToDate httpswww-uptodate-comoverview-of-chronic-kidney-disease-mineral-and-bone-disorder-ckd-mbd
bull Rosenberg M (2016 Feb 24) Overview of the management of chronic kidney disease in adults (G C Curhan amp A M Sheridan Eds) Retrieved from UpToDate UpToDate httpswww-uptodate-comproxywichitaeducontentsoverview-of-the-management-of-chronic-kidney-disease-in-adults
BIBLIOGRAPHY
bull Szczech L Stewart R C Hsu-Lin S DeLosky R J Astor B C Fox C H Vassalotti J A (2014) Primary care detection of chronic kidney disease in adults with type 2 diabetes The ADD-CKD Study (Awareness Detection and Drug Therapy in type 2 diabetes and chronic kidney disease PLOS doihttpsdoiorg101371journalpone0110535
bull USRDS (2016) Annual data report 2016 Epidemiology of kidney disease in the United States Retrieved from United States Renal Data System httpswwwusrdsorgadraspx
bull Vasudev B amp Vasudev M (2012) A model curriculum for residents rotating in nephrology MedEDPORTAL doihttpdoiorg1015766mep_2374-82658288
bull Wei L MacDonald T M Jennings C Sheng X amp Flynn R W (2013) Estimated GFR reporting is associated with decreased nonsteroidal anti-inflammatory drug prescribing and increased renal function Kidney International (84)1 174-178
chronic kidney disease in primary care
CKD as a Public Health Issue
Slide Number 3
Costs of CKD in 2013 dollarsUSRDS report
Steps to CKD Patient Care
Renal anatomy and physiology
Definition of Chronic Kidney Disease
CKD Risk Factors
Gaps in CKD Diagnosis
Slide Number 10
Steps to CKD Patient Care
creatinine
Glomerular filtration rate
Slide Number 14
Slide Number 15
Use These Equations Cautiously if at all in hellip
lab albumin creatinine ratio
The New CKD Categories
Steps to CKD Patient Care
Slide Number 20
Kidney Involvement in Systemic Diseases
Slide Number 22
Slide Number 23
DysmorphicRenal Hematuria
Slide Number 25
If you have albuminuria or hematuria-order the following labs
Prevalence of Abnormalities of Mineral Metabolism PTH in CKD
Managing CKD-MBD complications
CKD-MBD Testing
Anemia Becomes More Common as Kidney Function Declines
Detect and Manage CKD Complications
Complications-metabolic acidosis
Complications-vascular calcification
Hyperkalemia management
Hyperuricemia levels amp CKD
CKD monitoring levels 345
Slide Number 59
When to Refer to a Nephrologist
When to Refer
Steps to CKD Patient Care
Kidney transplantation
Starting Dialysis in the ElderlyhellipOr Not
Ckd management
Case 1
Slide Number 67
Lab results
Slide Number 69
Hypertensive nephropathy with proteinuria
Slide Number 71
Case 2
Slide Number 73
Management of CKD in Diabetes
Case 3
Case 3
Systemic Lupus Erythematosus (SLE)
SLE ndash Lupus Nephritis
Case 5
Case 5
Slide Number 81
Slide Number 82
Case study
Slide Number 84
CXR ndash Hilar Lymphadenopathy
Whats needed next
Slide Number 87
newly dx ckd
Slide Number 89
Bibliography
bibliography
bibliography
bibliography
bibliography
Intratubular refractile casts with surrounding syncytial giant cell reaction with chronic tubulointerstitial nephritis and fibrosis characteristic of myeloma cast nephropathy
Kidney Biopsy
CASE STUDYbull A 35 year old African American woman was seen in the clinic for
chronic cough and dyspnea on exertion She gave history of vague symptoms of fatigue and weight loss of 20 Ibs over the last six months
bull List some differentialsbull TB sarcoid lupus thyroid problems PEbull What would you orderbull PPD cbc cmp UA TSH ANA pa and lat cxr
bull Her labs were significant for mildly elevated calcium level and a creatinine of 20 mgdL eGFR 37
bull She had 750 mg of proteinuriaday
bull PPD neg ANA neg TSH and other labs WNL
bull Assuming this is present more than 3 monthshelliphellipwhat is her ckd stage
bull G3b A3
bull What do we still need
CT scan of chest
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileAnterior_mediastinal_mass_thymomajpgCreative Commons License associated httpcreativecommonsorglicensesby20deeden
CXR ndash HILAR LYMPHADENOPATHY
WHATS NEEDED NEXT
bull Biopsy of hilar lymphadenopathy or renal biopsy
bull DX sarcoidosis
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileSarcoidosis_signs_and_symptomsjpgThis work is in the public domain in the United States because it is a work of the United States Federal Government under the terms of Title 17 Chapter 1 Section 105 of the US Code
NEWLY DX CKD
bull 1) urinalysis microscopy ultrasound proteincr ratio
bull If obstruction-treat
bull No obstruction
bull Hx critical (consider myeloma if high risk)
bull glomerular bleeding or albumin in urine
bull Yes workup for glomerular causes (ANArf hep B C upep spep ANCA complement C3 C4)
bull No sterile pyruria-consider interstitial nephritis
bull High risk renovascular disease Evaluate renovascular disease
Additional Online Resources for CKD LearningbullNational Kidney Foundation wwwkidneyorgbullUnited States Renal Data Service wwwusrdsorgbullCDCrsquos CKD Surveillance Project
httpnccdcdcgovckdbullNational Kidney Disease Education Program
(NKDEP) httpnkdepnihgov
BIBLIOGRAPHY
bull Afzali B amp Goldsmith D J (2016 June 29) Statins and chronic kidney disease (G C Curhan amp A M Sheridan Eds) Retrieved 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsstatins-and-chronic-kidney-disease
bull American Diabetes Association Standards of Medical Care in Diabetes (2017) Microvascular complications and foot care Diabetes Care 2017 (40) S88-S98
bull American Diabetes Association Standards of Medical Care in Diabetes (2017) Microvascular complications and foot care Diabetes Care 40 (suppl 1) S88-S98
bull Berns J S (2017 Mar 22) Treatment of anemia in nondialysis chronic kidney disease (T A Golper amp A M Sheridan Eds) Retrieved from UpToDate httpswww-uptodate-comproxywichitaeducontentstreatment-of-anemia-in-nondialysis-chronic-kidney-disease
bull Chan M Dall A T Fletcher K E Lu N amp Trivedi H (2007) Outcomes in patients with chronic kidney disease referred late to nephrologists a meta-analysis American Journal of Medicine 120(12) 1063-1070
bull Coresh J Selvin E amp Stevens L A (2007) Prevalence of chronic kidny disease in the United States JAMA 298(17) doi101001jama298172038
bull de Brito-Ashurst I Varagunam M Raftery M amp Yagoob M (2009) Bicarbonate supplementation slows progression of CKD and improves nutritional status Journal of American Society of Nephrology (20) 2075-2084
BIBLIOGRAPHY
bull Duncan L Heathcoat J Djurdjev O amp Levin A (2001) Screening for renal disease using serum creatinine who are we missing Nephrology Dialysis and Transplant 16(5) 1042-1046
bull Dunkler D Gao P Lee S F Heinz G Clase C M Tobe S Oberbauer R (2015 August 7) Risk prediction for early CKD in type 2 diabetes Retrieved from Clinical Journal of the American Society of Nephrology httpcjasnasnjournalsorgcontent1081371fullsid=61422554-a5f1-41ac-b696-dcd3b12bd268
bull Fatehi P amp Chi-yuan H (September 15 2016) Diagnostic approach to the patient with newly identified chronic kidney disease (G C Curhan amp A M Sheridan Eds) Retrieved May 7 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsdiagnostic-approach-to-the-patient-with-newly-identified-chronic-kidney-disease
bull Fink J e (2009) Chronic Kidney Disease as an Under-Recognized Threat to Patient Safety American journal of kidney diseases the official journal of the National Kidney Foundation 53(4) 681-688
bull Gaffo A L amp Saag K G (2008 Nov) Management of hyperuricemia and gout in CKD doihttpdxdoiorg101053jajkd200807035
bull Hebert L A amp Parikh S V (2014 June 18) Differential diagnosis and evaluation of glomerular disease (R J Glassock amp A Q Lam Eds) Retrieved May 7 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsdifferential-diagnosis-and-evaluation-of-glomerular-disease
bull Inker L Perrone R D Sterns R H amp Forman J P (2017 March 7) Assessment of kidney function Retrieved from UpToDate httpswww-uptodate-comproxywichitaeducontentsassessment-of-kidney-functionsource=search_resultampsearch=creatinineampselectedTitle=1~150
BIBLIOGRAPHY
bull James P A Ortiz E amp Et Al (2014) Evidence based guideline for the management of high blood pressure in adults (JNC) JAMA 311(5) 507-520
bull Kidney Disease Improving Global Outcomes (KDIGO) CKD Work Group (2013 January) KDIGO 2012 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease Retrieved from Kidney International Supplement httpwwwkidney-internationalorg
bull Kunz R Friedrich C Wolbers M amp Mann J F (2008) Meta-analysis effect of monotherapy and combination therapy with inhibitors of the renin angiotensin system on proteinuria in renal disease Annals of Internal Medicine 148(1) 30-48
bull Levey A Stevens L A Schmid C H Castro A F Feldman H I Kusek J W Coresh J (2009) A new equation to estimate glomerular filtration rate Annals of Internal Medicine 150(9) 604-612
bull Levin A Bakris G L Molitch M Smulders M M Williams L A amp Andress D L (2007 Jan) Prevalence of abnormal serum vitamin D PTH calcium and phosphorus in patients with chronic kidney disease results of the study to evaluate early kidney disease Kidney International 71(1) 31-38 Retrieved from PubMED
bull Mahajan A Simoni J Sheather S Broglio K Rajab M amp Wesson D (2010) Daily oral sodium bicarbonate preserves glomerular filtration rate by slowing its decline in early hypertensive nephropathy Kidney International (78_ 303-309
bull Mann J Schmieder R E amp McQueen M (2008) Renal outcomes with telmisartan ramipril or both in people at high vascular risk (the ONTARGET study) a multicentre randomised doubleblind ocntrolled trial Lancet 372(9638) 547-533
BIBLIOGRAPHY
bull Matovinović M S (2009) Pathophysiology and classification of kidney disease Retrieved from The Journal of the International Federation of Clinical Chemistry and Laboratory Medicine httpwwwifccorgifccfilesdocs20010902pdf
bull Moe S Drueke T Lameire N amp Eknoyan G (2007 Jan) Chronic kidney disease-mineral-bone disorder a new paradigmdoi101053jackd200610005
bull Murtagh F E Marsh J E Donohoe P Ekbal N J Sheerin N S amp Harris F E (2007 July) Dialysis or not A comparative survival study of patients over 75 years with chronic kidney disease stage 5 Retrieved from Nephrology Dialysis and Transplant 22(7) httpswwwncbinlmnihgovpubmed17412702
bull National Kidney Foundation (2002) KDOQI clinical practice guidelines for chronic kidney disease evaluation classification andstratification American Journal of Kidney Disease S1-S266
bull National Kidney Foundation (2014 November 5) Fact Sheets Retrieved from httpwwwkidneyorgnewsnewsroomfactsheetsFastFacts
bull Pal S (2012 June 2) Trends in chronic kidney disease Retrieved from US Pharmacist (37)6 httpswwwuspharmacistcomarticletrends-in-chronic-kidney-disease
bull Qunibi W amp Henrich W L (2017 Jan 19) Overview of chronic kidney disease-mineral and bone disorder (J Berns amp A M Sheridan Eds) Retrieved from UpToDate httpswww-uptodate-comoverview-of-chronic-kidney-disease-mineral-and-bone-disorder-ckd-mbd
bull Rosenberg M (2016 Feb 24) Overview of the management of chronic kidney disease in adults (G C Curhan amp A M Sheridan Eds) Retrieved from UpToDate UpToDate httpswww-uptodate-comproxywichitaeducontentsoverview-of-the-management-of-chronic-kidney-disease-in-adults
BIBLIOGRAPHY
bull Szczech L Stewart R C Hsu-Lin S DeLosky R J Astor B C Fox C H Vassalotti J A (2014) Primary care detection of chronic kidney disease in adults with type 2 diabetes The ADD-CKD Study (Awareness Detection and Drug Therapy in type 2 diabetes and chronic kidney disease PLOS doihttpsdoiorg101371journalpone0110535
bull USRDS (2016) Annual data report 2016 Epidemiology of kidney disease in the United States Retrieved from United States Renal Data System httpswwwusrdsorgadraspx
bull Vasudev B amp Vasudev M (2012) A model curriculum for residents rotating in nephrology MedEDPORTAL doihttpdoiorg1015766mep_2374-82658288
bull Wei L MacDonald T M Jennings C Sheng X amp Flynn R W (2013) Estimated GFR reporting is associated with decreased nonsteroidal anti-inflammatory drug prescribing and increased renal function Kidney International (84)1 174-178
chronic kidney disease in primary care
CKD as a Public Health Issue
Slide Number 3
Costs of CKD in 2013 dollarsUSRDS report
Steps to CKD Patient Care
Renal anatomy and physiology
Definition of Chronic Kidney Disease
CKD Risk Factors
Gaps in CKD Diagnosis
Slide Number 10
Steps to CKD Patient Care
creatinine
Glomerular filtration rate
Slide Number 14
Slide Number 15
Use These Equations Cautiously if at all in hellip
lab albumin creatinine ratio
The New CKD Categories
Steps to CKD Patient Care
Slide Number 20
Kidney Involvement in Systemic Diseases
Slide Number 22
Slide Number 23
DysmorphicRenal Hematuria
Slide Number 25
If you have albuminuria or hematuria-order the following labs
Prevalence of Abnormalities of Mineral Metabolism PTH in CKD
Managing CKD-MBD complications
CKD-MBD Testing
Anemia Becomes More Common as Kidney Function Declines
Detect and Manage CKD Complications
Complications-metabolic acidosis
Complications-vascular calcification
Hyperkalemia management
Hyperuricemia levels amp CKD
CKD monitoring levels 345
Slide Number 59
When to Refer to a Nephrologist
When to Refer
Steps to CKD Patient Care
Kidney transplantation
Starting Dialysis in the ElderlyhellipOr Not
Ckd management
Case 1
Slide Number 67
Lab results
Slide Number 69
Hypertensive nephropathy with proteinuria
Slide Number 71
Case 2
Slide Number 73
Management of CKD in Diabetes
Case 3
Case 3
Systemic Lupus Erythematosus (SLE)
SLE ndash Lupus Nephritis
Case 5
Case 5
Slide Number 81
Slide Number 82
Case study
Slide Number 84
CXR ndash Hilar Lymphadenopathy
Whats needed next
Slide Number 87
newly dx ckd
Slide Number 89
Bibliography
bibliography
bibliography
bibliography
bibliography
CASE STUDYbull A 35 year old African American woman was seen in the clinic for
chronic cough and dyspnea on exertion She gave history of vague symptoms of fatigue and weight loss of 20 Ibs over the last six months
bull List some differentialsbull TB sarcoid lupus thyroid problems PEbull What would you orderbull PPD cbc cmp UA TSH ANA pa and lat cxr
bull Her labs were significant for mildly elevated calcium level and a creatinine of 20 mgdL eGFR 37
bull She had 750 mg of proteinuriaday
bull PPD neg ANA neg TSH and other labs WNL
bull Assuming this is present more than 3 monthshelliphellipwhat is her ckd stage
bull G3b A3
bull What do we still need
CT scan of chest
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileAnterior_mediastinal_mass_thymomajpgCreative Commons License associated httpcreativecommonsorglicensesby20deeden
CXR ndash HILAR LYMPHADENOPATHY
WHATS NEEDED NEXT
bull Biopsy of hilar lymphadenopathy or renal biopsy
bull DX sarcoidosis
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileSarcoidosis_signs_and_symptomsjpgThis work is in the public domain in the United States because it is a work of the United States Federal Government under the terms of Title 17 Chapter 1 Section 105 of the US Code
NEWLY DX CKD
bull 1) urinalysis microscopy ultrasound proteincr ratio
bull If obstruction-treat
bull No obstruction
bull Hx critical (consider myeloma if high risk)
bull glomerular bleeding or albumin in urine
bull Yes workup for glomerular causes (ANArf hep B C upep spep ANCA complement C3 C4)
bull No sterile pyruria-consider interstitial nephritis
bull High risk renovascular disease Evaluate renovascular disease
Additional Online Resources for CKD LearningbullNational Kidney Foundation wwwkidneyorgbullUnited States Renal Data Service wwwusrdsorgbullCDCrsquos CKD Surveillance Project
httpnccdcdcgovckdbullNational Kidney Disease Education Program
(NKDEP) httpnkdepnihgov
BIBLIOGRAPHY
bull Afzali B amp Goldsmith D J (2016 June 29) Statins and chronic kidney disease (G C Curhan amp A M Sheridan Eds) Retrieved 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsstatins-and-chronic-kidney-disease
bull American Diabetes Association Standards of Medical Care in Diabetes (2017) Microvascular complications and foot care Diabetes Care 2017 (40) S88-S98
bull American Diabetes Association Standards of Medical Care in Diabetes (2017) Microvascular complications and foot care Diabetes Care 40 (suppl 1) S88-S98
bull Berns J S (2017 Mar 22) Treatment of anemia in nondialysis chronic kidney disease (T A Golper amp A M Sheridan Eds) Retrieved from UpToDate httpswww-uptodate-comproxywichitaeducontentstreatment-of-anemia-in-nondialysis-chronic-kidney-disease
bull Chan M Dall A T Fletcher K E Lu N amp Trivedi H (2007) Outcomes in patients with chronic kidney disease referred late to nephrologists a meta-analysis American Journal of Medicine 120(12) 1063-1070
bull Coresh J Selvin E amp Stevens L A (2007) Prevalence of chronic kidny disease in the United States JAMA 298(17) doi101001jama298172038
bull de Brito-Ashurst I Varagunam M Raftery M amp Yagoob M (2009) Bicarbonate supplementation slows progression of CKD and improves nutritional status Journal of American Society of Nephrology (20) 2075-2084
BIBLIOGRAPHY
bull Duncan L Heathcoat J Djurdjev O amp Levin A (2001) Screening for renal disease using serum creatinine who are we missing Nephrology Dialysis and Transplant 16(5) 1042-1046
bull Dunkler D Gao P Lee S F Heinz G Clase C M Tobe S Oberbauer R (2015 August 7) Risk prediction for early CKD in type 2 diabetes Retrieved from Clinical Journal of the American Society of Nephrology httpcjasnasnjournalsorgcontent1081371fullsid=61422554-a5f1-41ac-b696-dcd3b12bd268
bull Fatehi P amp Chi-yuan H (September 15 2016) Diagnostic approach to the patient with newly identified chronic kidney disease (G C Curhan amp A M Sheridan Eds) Retrieved May 7 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsdiagnostic-approach-to-the-patient-with-newly-identified-chronic-kidney-disease
bull Fink J e (2009) Chronic Kidney Disease as an Under-Recognized Threat to Patient Safety American journal of kidney diseases the official journal of the National Kidney Foundation 53(4) 681-688
bull Gaffo A L amp Saag K G (2008 Nov) Management of hyperuricemia and gout in CKD doihttpdxdoiorg101053jajkd200807035
bull Hebert L A amp Parikh S V (2014 June 18) Differential diagnosis and evaluation of glomerular disease (R J Glassock amp A Q Lam Eds) Retrieved May 7 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsdifferential-diagnosis-and-evaluation-of-glomerular-disease
bull Inker L Perrone R D Sterns R H amp Forman J P (2017 March 7) Assessment of kidney function Retrieved from UpToDate httpswww-uptodate-comproxywichitaeducontentsassessment-of-kidney-functionsource=search_resultampsearch=creatinineampselectedTitle=1~150
BIBLIOGRAPHY
bull James P A Ortiz E amp Et Al (2014) Evidence based guideline for the management of high blood pressure in adults (JNC) JAMA 311(5) 507-520
bull Kidney Disease Improving Global Outcomes (KDIGO) CKD Work Group (2013 January) KDIGO 2012 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease Retrieved from Kidney International Supplement httpwwwkidney-internationalorg
bull Kunz R Friedrich C Wolbers M amp Mann J F (2008) Meta-analysis effect of monotherapy and combination therapy with inhibitors of the renin angiotensin system on proteinuria in renal disease Annals of Internal Medicine 148(1) 30-48
bull Levey A Stevens L A Schmid C H Castro A F Feldman H I Kusek J W Coresh J (2009) A new equation to estimate glomerular filtration rate Annals of Internal Medicine 150(9) 604-612
bull Levin A Bakris G L Molitch M Smulders M M Williams L A amp Andress D L (2007 Jan) Prevalence of abnormal serum vitamin D PTH calcium and phosphorus in patients with chronic kidney disease results of the study to evaluate early kidney disease Kidney International 71(1) 31-38 Retrieved from PubMED
bull Mahajan A Simoni J Sheather S Broglio K Rajab M amp Wesson D (2010) Daily oral sodium bicarbonate preserves glomerular filtration rate by slowing its decline in early hypertensive nephropathy Kidney International (78_ 303-309
bull Mann J Schmieder R E amp McQueen M (2008) Renal outcomes with telmisartan ramipril or both in people at high vascular risk (the ONTARGET study) a multicentre randomised doubleblind ocntrolled trial Lancet 372(9638) 547-533
BIBLIOGRAPHY
bull Matovinović M S (2009) Pathophysiology and classification of kidney disease Retrieved from The Journal of the International Federation of Clinical Chemistry and Laboratory Medicine httpwwwifccorgifccfilesdocs20010902pdf
bull Moe S Drueke T Lameire N amp Eknoyan G (2007 Jan) Chronic kidney disease-mineral-bone disorder a new paradigmdoi101053jackd200610005
bull Murtagh F E Marsh J E Donohoe P Ekbal N J Sheerin N S amp Harris F E (2007 July) Dialysis or not A comparative survival study of patients over 75 years with chronic kidney disease stage 5 Retrieved from Nephrology Dialysis and Transplant 22(7) httpswwwncbinlmnihgovpubmed17412702
bull National Kidney Foundation (2002) KDOQI clinical practice guidelines for chronic kidney disease evaluation classification andstratification American Journal of Kidney Disease S1-S266
bull National Kidney Foundation (2014 November 5) Fact Sheets Retrieved from httpwwwkidneyorgnewsnewsroomfactsheetsFastFacts
bull Pal S (2012 June 2) Trends in chronic kidney disease Retrieved from US Pharmacist (37)6 httpswwwuspharmacistcomarticletrends-in-chronic-kidney-disease
bull Qunibi W amp Henrich W L (2017 Jan 19) Overview of chronic kidney disease-mineral and bone disorder (J Berns amp A M Sheridan Eds) Retrieved from UpToDate httpswww-uptodate-comoverview-of-chronic-kidney-disease-mineral-and-bone-disorder-ckd-mbd
bull Rosenberg M (2016 Feb 24) Overview of the management of chronic kidney disease in adults (G C Curhan amp A M Sheridan Eds) Retrieved from UpToDate UpToDate httpswww-uptodate-comproxywichitaeducontentsoverview-of-the-management-of-chronic-kidney-disease-in-adults
BIBLIOGRAPHY
bull Szczech L Stewart R C Hsu-Lin S DeLosky R J Astor B C Fox C H Vassalotti J A (2014) Primary care detection of chronic kidney disease in adults with type 2 diabetes The ADD-CKD Study (Awareness Detection and Drug Therapy in type 2 diabetes and chronic kidney disease PLOS doihttpsdoiorg101371journalpone0110535
bull USRDS (2016) Annual data report 2016 Epidemiology of kidney disease in the United States Retrieved from United States Renal Data System httpswwwusrdsorgadraspx
bull Vasudev B amp Vasudev M (2012) A model curriculum for residents rotating in nephrology MedEDPORTAL doihttpdoiorg1015766mep_2374-82658288
bull Wei L MacDonald T M Jennings C Sheng X amp Flynn R W (2013) Estimated GFR reporting is associated with decreased nonsteroidal anti-inflammatory drug prescribing and increased renal function Kidney International (84)1 174-178
chronic kidney disease in primary care
CKD as a Public Health Issue
Slide Number 3
Costs of CKD in 2013 dollarsUSRDS report
Steps to CKD Patient Care
Renal anatomy and physiology
Definition of Chronic Kidney Disease
CKD Risk Factors
Gaps in CKD Diagnosis
Slide Number 10
Steps to CKD Patient Care
creatinine
Glomerular filtration rate
Slide Number 14
Slide Number 15
Use These Equations Cautiously if at all in hellip
lab albumin creatinine ratio
The New CKD Categories
Steps to CKD Patient Care
Slide Number 20
Kidney Involvement in Systemic Diseases
Slide Number 22
Slide Number 23
DysmorphicRenal Hematuria
Slide Number 25
If you have albuminuria or hematuria-order the following labs
Prevalence of Abnormalities of Mineral Metabolism PTH in CKD
Managing CKD-MBD complications
CKD-MBD Testing
Anemia Becomes More Common as Kidney Function Declines
Detect and Manage CKD Complications
Complications-metabolic acidosis
Complications-vascular calcification
Hyperkalemia management
Hyperuricemia levels amp CKD
CKD monitoring levels 345
Slide Number 59
When to Refer to a Nephrologist
When to Refer
Steps to CKD Patient Care
Kidney transplantation
Starting Dialysis in the ElderlyhellipOr Not
Ckd management
Case 1
Slide Number 67
Lab results
Slide Number 69
Hypertensive nephropathy with proteinuria
Slide Number 71
Case 2
Slide Number 73
Management of CKD in Diabetes
Case 3
Case 3
Systemic Lupus Erythematosus (SLE)
SLE ndash Lupus Nephritis
Case 5
Case 5
Slide Number 81
Slide Number 82
Case study
Slide Number 84
CXR ndash Hilar Lymphadenopathy
Whats needed next
Slide Number 87
newly dx ckd
Slide Number 89
Bibliography
bibliography
bibliography
bibliography
bibliography
bull Her labs were significant for mildly elevated calcium level and a creatinine of 20 mgdL eGFR 37
bull She had 750 mg of proteinuriaday
bull PPD neg ANA neg TSH and other labs WNL
bull Assuming this is present more than 3 monthshelliphellipwhat is her ckd stage
bull G3b A3
bull What do we still need
CT scan of chest
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileAnterior_mediastinal_mass_thymomajpgCreative Commons License associated httpcreativecommonsorglicensesby20deeden
CXR ndash HILAR LYMPHADENOPATHY
WHATS NEEDED NEXT
bull Biopsy of hilar lymphadenopathy or renal biopsy
bull DX sarcoidosis
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileSarcoidosis_signs_and_symptomsjpgThis work is in the public domain in the United States because it is a work of the United States Federal Government under the terms of Title 17 Chapter 1 Section 105 of the US Code
NEWLY DX CKD
bull 1) urinalysis microscopy ultrasound proteincr ratio
bull If obstruction-treat
bull No obstruction
bull Hx critical (consider myeloma if high risk)
bull glomerular bleeding or albumin in urine
bull Yes workup for glomerular causes (ANArf hep B C upep spep ANCA complement C3 C4)
bull No sterile pyruria-consider interstitial nephritis
bull High risk renovascular disease Evaluate renovascular disease
Additional Online Resources for CKD LearningbullNational Kidney Foundation wwwkidneyorgbullUnited States Renal Data Service wwwusrdsorgbullCDCrsquos CKD Surveillance Project
httpnccdcdcgovckdbullNational Kidney Disease Education Program
(NKDEP) httpnkdepnihgov
BIBLIOGRAPHY
bull Afzali B amp Goldsmith D J (2016 June 29) Statins and chronic kidney disease (G C Curhan amp A M Sheridan Eds) Retrieved 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsstatins-and-chronic-kidney-disease
bull American Diabetes Association Standards of Medical Care in Diabetes (2017) Microvascular complications and foot care Diabetes Care 2017 (40) S88-S98
bull American Diabetes Association Standards of Medical Care in Diabetes (2017) Microvascular complications and foot care Diabetes Care 40 (suppl 1) S88-S98
bull Berns J S (2017 Mar 22) Treatment of anemia in nondialysis chronic kidney disease (T A Golper amp A M Sheridan Eds) Retrieved from UpToDate httpswww-uptodate-comproxywichitaeducontentstreatment-of-anemia-in-nondialysis-chronic-kidney-disease
bull Chan M Dall A T Fletcher K E Lu N amp Trivedi H (2007) Outcomes in patients with chronic kidney disease referred late to nephrologists a meta-analysis American Journal of Medicine 120(12) 1063-1070
bull Coresh J Selvin E amp Stevens L A (2007) Prevalence of chronic kidny disease in the United States JAMA 298(17) doi101001jama298172038
bull de Brito-Ashurst I Varagunam M Raftery M amp Yagoob M (2009) Bicarbonate supplementation slows progression of CKD and improves nutritional status Journal of American Society of Nephrology (20) 2075-2084
BIBLIOGRAPHY
bull Duncan L Heathcoat J Djurdjev O amp Levin A (2001) Screening for renal disease using serum creatinine who are we missing Nephrology Dialysis and Transplant 16(5) 1042-1046
bull Dunkler D Gao P Lee S F Heinz G Clase C M Tobe S Oberbauer R (2015 August 7) Risk prediction for early CKD in type 2 diabetes Retrieved from Clinical Journal of the American Society of Nephrology httpcjasnasnjournalsorgcontent1081371fullsid=61422554-a5f1-41ac-b696-dcd3b12bd268
bull Fatehi P amp Chi-yuan H (September 15 2016) Diagnostic approach to the patient with newly identified chronic kidney disease (G C Curhan amp A M Sheridan Eds) Retrieved May 7 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsdiagnostic-approach-to-the-patient-with-newly-identified-chronic-kidney-disease
bull Fink J e (2009) Chronic Kidney Disease as an Under-Recognized Threat to Patient Safety American journal of kidney diseases the official journal of the National Kidney Foundation 53(4) 681-688
bull Gaffo A L amp Saag K G (2008 Nov) Management of hyperuricemia and gout in CKD doihttpdxdoiorg101053jajkd200807035
bull Hebert L A amp Parikh S V (2014 June 18) Differential diagnosis and evaluation of glomerular disease (R J Glassock amp A Q Lam Eds) Retrieved May 7 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsdifferential-diagnosis-and-evaluation-of-glomerular-disease
bull Inker L Perrone R D Sterns R H amp Forman J P (2017 March 7) Assessment of kidney function Retrieved from UpToDate httpswww-uptodate-comproxywichitaeducontentsassessment-of-kidney-functionsource=search_resultampsearch=creatinineampselectedTitle=1~150
BIBLIOGRAPHY
bull James P A Ortiz E amp Et Al (2014) Evidence based guideline for the management of high blood pressure in adults (JNC) JAMA 311(5) 507-520
bull Kidney Disease Improving Global Outcomes (KDIGO) CKD Work Group (2013 January) KDIGO 2012 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease Retrieved from Kidney International Supplement httpwwwkidney-internationalorg
bull Kunz R Friedrich C Wolbers M amp Mann J F (2008) Meta-analysis effect of monotherapy and combination therapy with inhibitors of the renin angiotensin system on proteinuria in renal disease Annals of Internal Medicine 148(1) 30-48
bull Levey A Stevens L A Schmid C H Castro A F Feldman H I Kusek J W Coresh J (2009) A new equation to estimate glomerular filtration rate Annals of Internal Medicine 150(9) 604-612
bull Levin A Bakris G L Molitch M Smulders M M Williams L A amp Andress D L (2007 Jan) Prevalence of abnormal serum vitamin D PTH calcium and phosphorus in patients with chronic kidney disease results of the study to evaluate early kidney disease Kidney International 71(1) 31-38 Retrieved from PubMED
bull Mahajan A Simoni J Sheather S Broglio K Rajab M amp Wesson D (2010) Daily oral sodium bicarbonate preserves glomerular filtration rate by slowing its decline in early hypertensive nephropathy Kidney International (78_ 303-309
bull Mann J Schmieder R E amp McQueen M (2008) Renal outcomes with telmisartan ramipril or both in people at high vascular risk (the ONTARGET study) a multicentre randomised doubleblind ocntrolled trial Lancet 372(9638) 547-533
BIBLIOGRAPHY
bull Matovinović M S (2009) Pathophysiology and classification of kidney disease Retrieved from The Journal of the International Federation of Clinical Chemistry and Laboratory Medicine httpwwwifccorgifccfilesdocs20010902pdf
bull Moe S Drueke T Lameire N amp Eknoyan G (2007 Jan) Chronic kidney disease-mineral-bone disorder a new paradigmdoi101053jackd200610005
bull Murtagh F E Marsh J E Donohoe P Ekbal N J Sheerin N S amp Harris F E (2007 July) Dialysis or not A comparative survival study of patients over 75 years with chronic kidney disease stage 5 Retrieved from Nephrology Dialysis and Transplant 22(7) httpswwwncbinlmnihgovpubmed17412702
bull National Kidney Foundation (2002) KDOQI clinical practice guidelines for chronic kidney disease evaluation classification andstratification American Journal of Kidney Disease S1-S266
bull National Kidney Foundation (2014 November 5) Fact Sheets Retrieved from httpwwwkidneyorgnewsnewsroomfactsheetsFastFacts
bull Pal S (2012 June 2) Trends in chronic kidney disease Retrieved from US Pharmacist (37)6 httpswwwuspharmacistcomarticletrends-in-chronic-kidney-disease
bull Qunibi W amp Henrich W L (2017 Jan 19) Overview of chronic kidney disease-mineral and bone disorder (J Berns amp A M Sheridan Eds) Retrieved from UpToDate httpswww-uptodate-comoverview-of-chronic-kidney-disease-mineral-and-bone-disorder-ckd-mbd
bull Rosenberg M (2016 Feb 24) Overview of the management of chronic kidney disease in adults (G C Curhan amp A M Sheridan Eds) Retrieved from UpToDate UpToDate httpswww-uptodate-comproxywichitaeducontentsoverview-of-the-management-of-chronic-kidney-disease-in-adults
BIBLIOGRAPHY
bull Szczech L Stewart R C Hsu-Lin S DeLosky R J Astor B C Fox C H Vassalotti J A (2014) Primary care detection of chronic kidney disease in adults with type 2 diabetes The ADD-CKD Study (Awareness Detection and Drug Therapy in type 2 diabetes and chronic kidney disease PLOS doihttpsdoiorg101371journalpone0110535
bull USRDS (2016) Annual data report 2016 Epidemiology of kidney disease in the United States Retrieved from United States Renal Data System httpswwwusrdsorgadraspx
bull Vasudev B amp Vasudev M (2012) A model curriculum for residents rotating in nephrology MedEDPORTAL doihttpdoiorg1015766mep_2374-82658288
bull Wei L MacDonald T M Jennings C Sheng X amp Flynn R W (2013) Estimated GFR reporting is associated with decreased nonsteroidal anti-inflammatory drug prescribing and increased renal function Kidney International (84)1 174-178
chronic kidney disease in primary care
CKD as a Public Health Issue
Slide Number 3
Costs of CKD in 2013 dollarsUSRDS report
Steps to CKD Patient Care
Renal anatomy and physiology
Definition of Chronic Kidney Disease
CKD Risk Factors
Gaps in CKD Diagnosis
Slide Number 10
Steps to CKD Patient Care
creatinine
Glomerular filtration rate
Slide Number 14
Slide Number 15
Use These Equations Cautiously if at all in hellip
lab albumin creatinine ratio
The New CKD Categories
Steps to CKD Patient Care
Slide Number 20
Kidney Involvement in Systemic Diseases
Slide Number 22
Slide Number 23
DysmorphicRenal Hematuria
Slide Number 25
If you have albuminuria or hematuria-order the following labs
Prevalence of Abnormalities of Mineral Metabolism PTH in CKD
Managing CKD-MBD complications
CKD-MBD Testing
Anemia Becomes More Common as Kidney Function Declines
Detect and Manage CKD Complications
Complications-metabolic acidosis
Complications-vascular calcification
Hyperkalemia management
Hyperuricemia levels amp CKD
CKD monitoring levels 345
Slide Number 59
When to Refer to a Nephrologist
When to Refer
Steps to CKD Patient Care
Kidney transplantation
Starting Dialysis in the ElderlyhellipOr Not
Ckd management
Case 1
Slide Number 67
Lab results
Slide Number 69
Hypertensive nephropathy with proteinuria
Slide Number 71
Case 2
Slide Number 73
Management of CKD in Diabetes
Case 3
Case 3
Systemic Lupus Erythematosus (SLE)
SLE ndash Lupus Nephritis
Case 5
Case 5
Slide Number 81
Slide Number 82
Case study
Slide Number 84
CXR ndash Hilar Lymphadenopathy
Whats needed next
Slide Number 87
newly dx ckd
Slide Number 89
Bibliography
bibliography
bibliography
bibliography
bibliography
CT scan of chest
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileAnterior_mediastinal_mass_thymomajpgCreative Commons License associated httpcreativecommonsorglicensesby20deeden
CXR ndash HILAR LYMPHADENOPATHY
WHATS NEEDED NEXT
bull Biopsy of hilar lymphadenopathy or renal biopsy
bull DX sarcoidosis
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileSarcoidosis_signs_and_symptomsjpgThis work is in the public domain in the United States because it is a work of the United States Federal Government under the terms of Title 17 Chapter 1 Section 105 of the US Code
NEWLY DX CKD
bull 1) urinalysis microscopy ultrasound proteincr ratio
bull If obstruction-treat
bull No obstruction
bull Hx critical (consider myeloma if high risk)
bull glomerular bleeding or albumin in urine
bull Yes workup for glomerular causes (ANArf hep B C upep spep ANCA complement C3 C4)
bull No sterile pyruria-consider interstitial nephritis
bull High risk renovascular disease Evaluate renovascular disease
Additional Online Resources for CKD LearningbullNational Kidney Foundation wwwkidneyorgbullUnited States Renal Data Service wwwusrdsorgbullCDCrsquos CKD Surveillance Project
httpnccdcdcgovckdbullNational Kidney Disease Education Program
(NKDEP) httpnkdepnihgov
BIBLIOGRAPHY
bull Afzali B amp Goldsmith D J (2016 June 29) Statins and chronic kidney disease (G C Curhan amp A M Sheridan Eds) Retrieved 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsstatins-and-chronic-kidney-disease
bull American Diabetes Association Standards of Medical Care in Diabetes (2017) Microvascular complications and foot care Diabetes Care 2017 (40) S88-S98
bull American Diabetes Association Standards of Medical Care in Diabetes (2017) Microvascular complications and foot care Diabetes Care 40 (suppl 1) S88-S98
bull Berns J S (2017 Mar 22) Treatment of anemia in nondialysis chronic kidney disease (T A Golper amp A M Sheridan Eds) Retrieved from UpToDate httpswww-uptodate-comproxywichitaeducontentstreatment-of-anemia-in-nondialysis-chronic-kidney-disease
bull Chan M Dall A T Fletcher K E Lu N amp Trivedi H (2007) Outcomes in patients with chronic kidney disease referred late to nephrologists a meta-analysis American Journal of Medicine 120(12) 1063-1070
bull Coresh J Selvin E amp Stevens L A (2007) Prevalence of chronic kidny disease in the United States JAMA 298(17) doi101001jama298172038
bull de Brito-Ashurst I Varagunam M Raftery M amp Yagoob M (2009) Bicarbonate supplementation slows progression of CKD and improves nutritional status Journal of American Society of Nephrology (20) 2075-2084
BIBLIOGRAPHY
bull Duncan L Heathcoat J Djurdjev O amp Levin A (2001) Screening for renal disease using serum creatinine who are we missing Nephrology Dialysis and Transplant 16(5) 1042-1046
bull Dunkler D Gao P Lee S F Heinz G Clase C M Tobe S Oberbauer R (2015 August 7) Risk prediction for early CKD in type 2 diabetes Retrieved from Clinical Journal of the American Society of Nephrology httpcjasnasnjournalsorgcontent1081371fullsid=61422554-a5f1-41ac-b696-dcd3b12bd268
bull Fatehi P amp Chi-yuan H (September 15 2016) Diagnostic approach to the patient with newly identified chronic kidney disease (G C Curhan amp A M Sheridan Eds) Retrieved May 7 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsdiagnostic-approach-to-the-patient-with-newly-identified-chronic-kidney-disease
bull Fink J e (2009) Chronic Kidney Disease as an Under-Recognized Threat to Patient Safety American journal of kidney diseases the official journal of the National Kidney Foundation 53(4) 681-688
bull Gaffo A L amp Saag K G (2008 Nov) Management of hyperuricemia and gout in CKD doihttpdxdoiorg101053jajkd200807035
bull Hebert L A amp Parikh S V (2014 June 18) Differential diagnosis and evaluation of glomerular disease (R J Glassock amp A Q Lam Eds) Retrieved May 7 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsdifferential-diagnosis-and-evaluation-of-glomerular-disease
bull Inker L Perrone R D Sterns R H amp Forman J P (2017 March 7) Assessment of kidney function Retrieved from UpToDate httpswww-uptodate-comproxywichitaeducontentsassessment-of-kidney-functionsource=search_resultampsearch=creatinineampselectedTitle=1~150
BIBLIOGRAPHY
bull James P A Ortiz E amp Et Al (2014) Evidence based guideline for the management of high blood pressure in adults (JNC) JAMA 311(5) 507-520
bull Kidney Disease Improving Global Outcomes (KDIGO) CKD Work Group (2013 January) KDIGO 2012 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease Retrieved from Kidney International Supplement httpwwwkidney-internationalorg
bull Kunz R Friedrich C Wolbers M amp Mann J F (2008) Meta-analysis effect of monotherapy and combination therapy with inhibitors of the renin angiotensin system on proteinuria in renal disease Annals of Internal Medicine 148(1) 30-48
bull Levey A Stevens L A Schmid C H Castro A F Feldman H I Kusek J W Coresh J (2009) A new equation to estimate glomerular filtration rate Annals of Internal Medicine 150(9) 604-612
bull Levin A Bakris G L Molitch M Smulders M M Williams L A amp Andress D L (2007 Jan) Prevalence of abnormal serum vitamin D PTH calcium and phosphorus in patients with chronic kidney disease results of the study to evaluate early kidney disease Kidney International 71(1) 31-38 Retrieved from PubMED
bull Mahajan A Simoni J Sheather S Broglio K Rajab M amp Wesson D (2010) Daily oral sodium bicarbonate preserves glomerular filtration rate by slowing its decline in early hypertensive nephropathy Kidney International (78_ 303-309
bull Mann J Schmieder R E amp McQueen M (2008) Renal outcomes with telmisartan ramipril or both in people at high vascular risk (the ONTARGET study) a multicentre randomised doubleblind ocntrolled trial Lancet 372(9638) 547-533
BIBLIOGRAPHY
bull Matovinović M S (2009) Pathophysiology and classification of kidney disease Retrieved from The Journal of the International Federation of Clinical Chemistry and Laboratory Medicine httpwwwifccorgifccfilesdocs20010902pdf
bull Moe S Drueke T Lameire N amp Eknoyan G (2007 Jan) Chronic kidney disease-mineral-bone disorder a new paradigmdoi101053jackd200610005
bull Murtagh F E Marsh J E Donohoe P Ekbal N J Sheerin N S amp Harris F E (2007 July) Dialysis or not A comparative survival study of patients over 75 years with chronic kidney disease stage 5 Retrieved from Nephrology Dialysis and Transplant 22(7) httpswwwncbinlmnihgovpubmed17412702
bull National Kidney Foundation (2002) KDOQI clinical practice guidelines for chronic kidney disease evaluation classification andstratification American Journal of Kidney Disease S1-S266
bull National Kidney Foundation (2014 November 5) Fact Sheets Retrieved from httpwwwkidneyorgnewsnewsroomfactsheetsFastFacts
bull Pal S (2012 June 2) Trends in chronic kidney disease Retrieved from US Pharmacist (37)6 httpswwwuspharmacistcomarticletrends-in-chronic-kidney-disease
bull Qunibi W amp Henrich W L (2017 Jan 19) Overview of chronic kidney disease-mineral and bone disorder (J Berns amp A M Sheridan Eds) Retrieved from UpToDate httpswww-uptodate-comoverview-of-chronic-kidney-disease-mineral-and-bone-disorder-ckd-mbd
bull Rosenberg M (2016 Feb 24) Overview of the management of chronic kidney disease in adults (G C Curhan amp A M Sheridan Eds) Retrieved from UpToDate UpToDate httpswww-uptodate-comproxywichitaeducontentsoverview-of-the-management-of-chronic-kidney-disease-in-adults
BIBLIOGRAPHY
bull Szczech L Stewart R C Hsu-Lin S DeLosky R J Astor B C Fox C H Vassalotti J A (2014) Primary care detection of chronic kidney disease in adults with type 2 diabetes The ADD-CKD Study (Awareness Detection and Drug Therapy in type 2 diabetes and chronic kidney disease PLOS doihttpsdoiorg101371journalpone0110535
bull USRDS (2016) Annual data report 2016 Epidemiology of kidney disease in the United States Retrieved from United States Renal Data System httpswwwusrdsorgadraspx
bull Vasudev B amp Vasudev M (2012) A model curriculum for residents rotating in nephrology MedEDPORTAL doihttpdoiorg1015766mep_2374-82658288
bull Wei L MacDonald T M Jennings C Sheng X amp Flynn R W (2013) Estimated GFR reporting is associated with decreased nonsteroidal anti-inflammatory drug prescribing and increased renal function Kidney International (84)1 174-178
chronic kidney disease in primary care
CKD as a Public Health Issue
Slide Number 3
Costs of CKD in 2013 dollarsUSRDS report
Steps to CKD Patient Care
Renal anatomy and physiology
Definition of Chronic Kidney Disease
CKD Risk Factors
Gaps in CKD Diagnosis
Slide Number 10
Steps to CKD Patient Care
creatinine
Glomerular filtration rate
Slide Number 14
Slide Number 15
Use These Equations Cautiously if at all in hellip
lab albumin creatinine ratio
The New CKD Categories
Steps to CKD Patient Care
Slide Number 20
Kidney Involvement in Systemic Diseases
Slide Number 22
Slide Number 23
DysmorphicRenal Hematuria
Slide Number 25
If you have albuminuria or hematuria-order the following labs
Prevalence of Abnormalities of Mineral Metabolism PTH in CKD
Managing CKD-MBD complications
CKD-MBD Testing
Anemia Becomes More Common as Kidney Function Declines
Detect and Manage CKD Complications
Complications-metabolic acidosis
Complications-vascular calcification
Hyperkalemia management
Hyperuricemia levels amp CKD
CKD monitoring levels 345
Slide Number 59
When to Refer to a Nephrologist
When to Refer
Steps to CKD Patient Care
Kidney transplantation
Starting Dialysis in the ElderlyhellipOr Not
Ckd management
Case 1
Slide Number 67
Lab results
Slide Number 69
Hypertensive nephropathy with proteinuria
Slide Number 71
Case 2
Slide Number 73
Management of CKD in Diabetes
Case 3
Case 3
Systemic Lupus Erythematosus (SLE)
SLE ndash Lupus Nephritis
Case 5
Case 5
Slide Number 81
Slide Number 82
Case study
Slide Number 84
CXR ndash Hilar Lymphadenopathy
Whats needed next
Slide Number 87
newly dx ckd
Slide Number 89
Bibliography
bibliography
bibliography
bibliography
bibliography
WHATS NEEDED NEXT
bull Biopsy of hilar lymphadenopathy or renal biopsy
bull DX sarcoidosis
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileSarcoidosis_signs_and_symptomsjpgThis work is in the public domain in the United States because it is a work of the United States Federal Government under the terms of Title 17 Chapter 1 Section 105 of the US Code
NEWLY DX CKD
bull 1) urinalysis microscopy ultrasound proteincr ratio
bull If obstruction-treat
bull No obstruction
bull Hx critical (consider myeloma if high risk)
bull glomerular bleeding or albumin in urine
bull Yes workup for glomerular causes (ANArf hep B C upep spep ANCA complement C3 C4)
bull No sterile pyruria-consider interstitial nephritis
bull High risk renovascular disease Evaluate renovascular disease
Additional Online Resources for CKD LearningbullNational Kidney Foundation wwwkidneyorgbullUnited States Renal Data Service wwwusrdsorgbullCDCrsquos CKD Surveillance Project
httpnccdcdcgovckdbullNational Kidney Disease Education Program
(NKDEP) httpnkdepnihgov
BIBLIOGRAPHY
bull Afzali B amp Goldsmith D J (2016 June 29) Statins and chronic kidney disease (G C Curhan amp A M Sheridan Eds) Retrieved 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsstatins-and-chronic-kidney-disease
bull American Diabetes Association Standards of Medical Care in Diabetes (2017) Microvascular complications and foot care Diabetes Care 2017 (40) S88-S98
bull American Diabetes Association Standards of Medical Care in Diabetes (2017) Microvascular complications and foot care Diabetes Care 40 (suppl 1) S88-S98
bull Berns J S (2017 Mar 22) Treatment of anemia in nondialysis chronic kidney disease (T A Golper amp A M Sheridan Eds) Retrieved from UpToDate httpswww-uptodate-comproxywichitaeducontentstreatment-of-anemia-in-nondialysis-chronic-kidney-disease
bull Chan M Dall A T Fletcher K E Lu N amp Trivedi H (2007) Outcomes in patients with chronic kidney disease referred late to nephrologists a meta-analysis American Journal of Medicine 120(12) 1063-1070
bull Coresh J Selvin E amp Stevens L A (2007) Prevalence of chronic kidny disease in the United States JAMA 298(17) doi101001jama298172038
bull de Brito-Ashurst I Varagunam M Raftery M amp Yagoob M (2009) Bicarbonate supplementation slows progression of CKD and improves nutritional status Journal of American Society of Nephrology (20) 2075-2084
BIBLIOGRAPHY
bull Duncan L Heathcoat J Djurdjev O amp Levin A (2001) Screening for renal disease using serum creatinine who are we missing Nephrology Dialysis and Transplant 16(5) 1042-1046
bull Dunkler D Gao P Lee S F Heinz G Clase C M Tobe S Oberbauer R (2015 August 7) Risk prediction for early CKD in type 2 diabetes Retrieved from Clinical Journal of the American Society of Nephrology httpcjasnasnjournalsorgcontent1081371fullsid=61422554-a5f1-41ac-b696-dcd3b12bd268
bull Fatehi P amp Chi-yuan H (September 15 2016) Diagnostic approach to the patient with newly identified chronic kidney disease (G C Curhan amp A M Sheridan Eds) Retrieved May 7 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsdiagnostic-approach-to-the-patient-with-newly-identified-chronic-kidney-disease
bull Fink J e (2009) Chronic Kidney Disease as an Under-Recognized Threat to Patient Safety American journal of kidney diseases the official journal of the National Kidney Foundation 53(4) 681-688
bull Gaffo A L amp Saag K G (2008 Nov) Management of hyperuricemia and gout in CKD doihttpdxdoiorg101053jajkd200807035
bull Hebert L A amp Parikh S V (2014 June 18) Differential diagnosis and evaluation of glomerular disease (R J Glassock amp A Q Lam Eds) Retrieved May 7 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsdifferential-diagnosis-and-evaluation-of-glomerular-disease
bull Inker L Perrone R D Sterns R H amp Forman J P (2017 March 7) Assessment of kidney function Retrieved from UpToDate httpswww-uptodate-comproxywichitaeducontentsassessment-of-kidney-functionsource=search_resultampsearch=creatinineampselectedTitle=1~150
BIBLIOGRAPHY
bull James P A Ortiz E amp Et Al (2014) Evidence based guideline for the management of high blood pressure in adults (JNC) JAMA 311(5) 507-520
bull Kidney Disease Improving Global Outcomes (KDIGO) CKD Work Group (2013 January) KDIGO 2012 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease Retrieved from Kidney International Supplement httpwwwkidney-internationalorg
bull Kunz R Friedrich C Wolbers M amp Mann J F (2008) Meta-analysis effect of monotherapy and combination therapy with inhibitors of the renin angiotensin system on proteinuria in renal disease Annals of Internal Medicine 148(1) 30-48
bull Levey A Stevens L A Schmid C H Castro A F Feldman H I Kusek J W Coresh J (2009) A new equation to estimate glomerular filtration rate Annals of Internal Medicine 150(9) 604-612
bull Levin A Bakris G L Molitch M Smulders M M Williams L A amp Andress D L (2007 Jan) Prevalence of abnormal serum vitamin D PTH calcium and phosphorus in patients with chronic kidney disease results of the study to evaluate early kidney disease Kidney International 71(1) 31-38 Retrieved from PubMED
bull Mahajan A Simoni J Sheather S Broglio K Rajab M amp Wesson D (2010) Daily oral sodium bicarbonate preserves glomerular filtration rate by slowing its decline in early hypertensive nephropathy Kidney International (78_ 303-309
bull Mann J Schmieder R E amp McQueen M (2008) Renal outcomes with telmisartan ramipril or both in people at high vascular risk (the ONTARGET study) a multicentre randomised doubleblind ocntrolled trial Lancet 372(9638) 547-533
BIBLIOGRAPHY
bull Matovinović M S (2009) Pathophysiology and classification of kidney disease Retrieved from The Journal of the International Federation of Clinical Chemistry and Laboratory Medicine httpwwwifccorgifccfilesdocs20010902pdf
bull Moe S Drueke T Lameire N amp Eknoyan G (2007 Jan) Chronic kidney disease-mineral-bone disorder a new paradigmdoi101053jackd200610005
bull Murtagh F E Marsh J E Donohoe P Ekbal N J Sheerin N S amp Harris F E (2007 July) Dialysis or not A comparative survival study of patients over 75 years with chronic kidney disease stage 5 Retrieved from Nephrology Dialysis and Transplant 22(7) httpswwwncbinlmnihgovpubmed17412702
bull National Kidney Foundation (2002) KDOQI clinical practice guidelines for chronic kidney disease evaluation classification andstratification American Journal of Kidney Disease S1-S266
bull National Kidney Foundation (2014 November 5) Fact Sheets Retrieved from httpwwwkidneyorgnewsnewsroomfactsheetsFastFacts
bull Pal S (2012 June 2) Trends in chronic kidney disease Retrieved from US Pharmacist (37)6 httpswwwuspharmacistcomarticletrends-in-chronic-kidney-disease
bull Qunibi W amp Henrich W L (2017 Jan 19) Overview of chronic kidney disease-mineral and bone disorder (J Berns amp A M Sheridan Eds) Retrieved from UpToDate httpswww-uptodate-comoverview-of-chronic-kidney-disease-mineral-and-bone-disorder-ckd-mbd
bull Rosenberg M (2016 Feb 24) Overview of the management of chronic kidney disease in adults (G C Curhan amp A M Sheridan Eds) Retrieved from UpToDate UpToDate httpswww-uptodate-comproxywichitaeducontentsoverview-of-the-management-of-chronic-kidney-disease-in-adults
BIBLIOGRAPHY
bull Szczech L Stewart R C Hsu-Lin S DeLosky R J Astor B C Fox C H Vassalotti J A (2014) Primary care detection of chronic kidney disease in adults with type 2 diabetes The ADD-CKD Study (Awareness Detection and Drug Therapy in type 2 diabetes and chronic kidney disease PLOS doihttpsdoiorg101371journalpone0110535
bull USRDS (2016) Annual data report 2016 Epidemiology of kidney disease in the United States Retrieved from United States Renal Data System httpswwwusrdsorgadraspx
bull Vasudev B amp Vasudev M (2012) A model curriculum for residents rotating in nephrology MedEDPORTAL doihttpdoiorg1015766mep_2374-82658288
bull Wei L MacDonald T M Jennings C Sheng X amp Flynn R W (2013) Estimated GFR reporting is associated with decreased nonsteroidal anti-inflammatory drug prescribing and increased renal function Kidney International (84)1 174-178
chronic kidney disease in primary care
CKD as a Public Health Issue
Slide Number 3
Costs of CKD in 2013 dollarsUSRDS report
Steps to CKD Patient Care
Renal anatomy and physiology
Definition of Chronic Kidney Disease
CKD Risk Factors
Gaps in CKD Diagnosis
Slide Number 10
Steps to CKD Patient Care
creatinine
Glomerular filtration rate
Slide Number 14
Slide Number 15
Use These Equations Cautiously if at all in hellip
lab albumin creatinine ratio
The New CKD Categories
Steps to CKD Patient Care
Slide Number 20
Kidney Involvement in Systemic Diseases
Slide Number 22
Slide Number 23
DysmorphicRenal Hematuria
Slide Number 25
If you have albuminuria or hematuria-order the following labs
Prevalence of Abnormalities of Mineral Metabolism PTH in CKD
Managing CKD-MBD complications
CKD-MBD Testing
Anemia Becomes More Common as Kidney Function Declines
Detect and Manage CKD Complications
Complications-metabolic acidosis
Complications-vascular calcification
Hyperkalemia management
Hyperuricemia levels amp CKD
CKD monitoring levels 345
Slide Number 59
When to Refer to a Nephrologist
When to Refer
Steps to CKD Patient Care
Kidney transplantation
Starting Dialysis in the ElderlyhellipOr Not
Ckd management
Case 1
Slide Number 67
Lab results
Slide Number 69
Hypertensive nephropathy with proteinuria
Slide Number 71
Case 2
Slide Number 73
Management of CKD in Diabetes
Case 3
Case 3
Systemic Lupus Erythematosus (SLE)
SLE ndash Lupus Nephritis
Case 5
Case 5
Slide Number 81
Slide Number 82
Case study
Slide Number 84
CXR ndash Hilar Lymphadenopathy
Whats needed next
Slide Number 87
newly dx ckd
Slide Number 89
Bibliography
bibliography
bibliography
bibliography
bibliography
Image retrieved on 05 October 2010 from httpcommonswikimediaorgwikiFileSarcoidosis_signs_and_symptomsjpgThis work is in the public domain in the United States because it is a work of the United States Federal Government under the terms of Title 17 Chapter 1 Section 105 of the US Code
NEWLY DX CKD
bull 1) urinalysis microscopy ultrasound proteincr ratio
bull If obstruction-treat
bull No obstruction
bull Hx critical (consider myeloma if high risk)
bull glomerular bleeding or albumin in urine
bull Yes workup for glomerular causes (ANArf hep B C upep spep ANCA complement C3 C4)
bull No sterile pyruria-consider interstitial nephritis
bull High risk renovascular disease Evaluate renovascular disease
Additional Online Resources for CKD LearningbullNational Kidney Foundation wwwkidneyorgbullUnited States Renal Data Service wwwusrdsorgbullCDCrsquos CKD Surveillance Project
httpnccdcdcgovckdbullNational Kidney Disease Education Program
(NKDEP) httpnkdepnihgov
BIBLIOGRAPHY
bull Afzali B amp Goldsmith D J (2016 June 29) Statins and chronic kidney disease (G C Curhan amp A M Sheridan Eds) Retrieved 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsstatins-and-chronic-kidney-disease
bull American Diabetes Association Standards of Medical Care in Diabetes (2017) Microvascular complications and foot care Diabetes Care 2017 (40) S88-S98
bull American Diabetes Association Standards of Medical Care in Diabetes (2017) Microvascular complications and foot care Diabetes Care 40 (suppl 1) S88-S98
bull Berns J S (2017 Mar 22) Treatment of anemia in nondialysis chronic kidney disease (T A Golper amp A M Sheridan Eds) Retrieved from UpToDate httpswww-uptodate-comproxywichitaeducontentstreatment-of-anemia-in-nondialysis-chronic-kidney-disease
bull Chan M Dall A T Fletcher K E Lu N amp Trivedi H (2007) Outcomes in patients with chronic kidney disease referred late to nephrologists a meta-analysis American Journal of Medicine 120(12) 1063-1070
bull Coresh J Selvin E amp Stevens L A (2007) Prevalence of chronic kidny disease in the United States JAMA 298(17) doi101001jama298172038
bull de Brito-Ashurst I Varagunam M Raftery M amp Yagoob M (2009) Bicarbonate supplementation slows progression of CKD and improves nutritional status Journal of American Society of Nephrology (20) 2075-2084
BIBLIOGRAPHY
bull Duncan L Heathcoat J Djurdjev O amp Levin A (2001) Screening for renal disease using serum creatinine who are we missing Nephrology Dialysis and Transplant 16(5) 1042-1046
bull Dunkler D Gao P Lee S F Heinz G Clase C M Tobe S Oberbauer R (2015 August 7) Risk prediction for early CKD in type 2 diabetes Retrieved from Clinical Journal of the American Society of Nephrology httpcjasnasnjournalsorgcontent1081371fullsid=61422554-a5f1-41ac-b696-dcd3b12bd268
bull Fatehi P amp Chi-yuan H (September 15 2016) Diagnostic approach to the patient with newly identified chronic kidney disease (G C Curhan amp A M Sheridan Eds) Retrieved May 7 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsdiagnostic-approach-to-the-patient-with-newly-identified-chronic-kidney-disease
bull Fink J e (2009) Chronic Kidney Disease as an Under-Recognized Threat to Patient Safety American journal of kidney diseases the official journal of the National Kidney Foundation 53(4) 681-688
bull Gaffo A L amp Saag K G (2008 Nov) Management of hyperuricemia and gout in CKD doihttpdxdoiorg101053jajkd200807035
bull Hebert L A amp Parikh S V (2014 June 18) Differential diagnosis and evaluation of glomerular disease (R J Glassock amp A Q Lam Eds) Retrieved May 7 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsdifferential-diagnosis-and-evaluation-of-glomerular-disease
bull Inker L Perrone R D Sterns R H amp Forman J P (2017 March 7) Assessment of kidney function Retrieved from UpToDate httpswww-uptodate-comproxywichitaeducontentsassessment-of-kidney-functionsource=search_resultampsearch=creatinineampselectedTitle=1~150
BIBLIOGRAPHY
bull James P A Ortiz E amp Et Al (2014) Evidence based guideline for the management of high blood pressure in adults (JNC) JAMA 311(5) 507-520
bull Kidney Disease Improving Global Outcomes (KDIGO) CKD Work Group (2013 January) KDIGO 2012 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease Retrieved from Kidney International Supplement httpwwwkidney-internationalorg
bull Kunz R Friedrich C Wolbers M amp Mann J F (2008) Meta-analysis effect of monotherapy and combination therapy with inhibitors of the renin angiotensin system on proteinuria in renal disease Annals of Internal Medicine 148(1) 30-48
bull Levey A Stevens L A Schmid C H Castro A F Feldman H I Kusek J W Coresh J (2009) A new equation to estimate glomerular filtration rate Annals of Internal Medicine 150(9) 604-612
bull Levin A Bakris G L Molitch M Smulders M M Williams L A amp Andress D L (2007 Jan) Prevalence of abnormal serum vitamin D PTH calcium and phosphorus in patients with chronic kidney disease results of the study to evaluate early kidney disease Kidney International 71(1) 31-38 Retrieved from PubMED
bull Mahajan A Simoni J Sheather S Broglio K Rajab M amp Wesson D (2010) Daily oral sodium bicarbonate preserves glomerular filtration rate by slowing its decline in early hypertensive nephropathy Kidney International (78_ 303-309
bull Mann J Schmieder R E amp McQueen M (2008) Renal outcomes with telmisartan ramipril or both in people at high vascular risk (the ONTARGET study) a multicentre randomised doubleblind ocntrolled trial Lancet 372(9638) 547-533
BIBLIOGRAPHY
bull Matovinović M S (2009) Pathophysiology and classification of kidney disease Retrieved from The Journal of the International Federation of Clinical Chemistry and Laboratory Medicine httpwwwifccorgifccfilesdocs20010902pdf
bull Moe S Drueke T Lameire N amp Eknoyan G (2007 Jan) Chronic kidney disease-mineral-bone disorder a new paradigmdoi101053jackd200610005
bull Murtagh F E Marsh J E Donohoe P Ekbal N J Sheerin N S amp Harris F E (2007 July) Dialysis or not A comparative survival study of patients over 75 years with chronic kidney disease stage 5 Retrieved from Nephrology Dialysis and Transplant 22(7) httpswwwncbinlmnihgovpubmed17412702
bull National Kidney Foundation (2002) KDOQI clinical practice guidelines for chronic kidney disease evaluation classification andstratification American Journal of Kidney Disease S1-S266
bull National Kidney Foundation (2014 November 5) Fact Sheets Retrieved from httpwwwkidneyorgnewsnewsroomfactsheetsFastFacts
bull Pal S (2012 June 2) Trends in chronic kidney disease Retrieved from US Pharmacist (37)6 httpswwwuspharmacistcomarticletrends-in-chronic-kidney-disease
bull Qunibi W amp Henrich W L (2017 Jan 19) Overview of chronic kidney disease-mineral and bone disorder (J Berns amp A M Sheridan Eds) Retrieved from UpToDate httpswww-uptodate-comoverview-of-chronic-kidney-disease-mineral-and-bone-disorder-ckd-mbd
bull Rosenberg M (2016 Feb 24) Overview of the management of chronic kidney disease in adults (G C Curhan amp A M Sheridan Eds) Retrieved from UpToDate UpToDate httpswww-uptodate-comproxywichitaeducontentsoverview-of-the-management-of-chronic-kidney-disease-in-adults
BIBLIOGRAPHY
bull Szczech L Stewart R C Hsu-Lin S DeLosky R J Astor B C Fox C H Vassalotti J A (2014) Primary care detection of chronic kidney disease in adults with type 2 diabetes The ADD-CKD Study (Awareness Detection and Drug Therapy in type 2 diabetes and chronic kidney disease PLOS doihttpsdoiorg101371journalpone0110535
bull USRDS (2016) Annual data report 2016 Epidemiology of kidney disease in the United States Retrieved from United States Renal Data System httpswwwusrdsorgadraspx
bull Vasudev B amp Vasudev M (2012) A model curriculum for residents rotating in nephrology MedEDPORTAL doihttpdoiorg1015766mep_2374-82658288
bull Wei L MacDonald T M Jennings C Sheng X amp Flynn R W (2013) Estimated GFR reporting is associated with decreased nonsteroidal anti-inflammatory drug prescribing and increased renal function Kidney International (84)1 174-178
chronic kidney disease in primary care
CKD as a Public Health Issue
Slide Number 3
Costs of CKD in 2013 dollarsUSRDS report
Steps to CKD Patient Care
Renal anatomy and physiology
Definition of Chronic Kidney Disease
CKD Risk Factors
Gaps in CKD Diagnosis
Slide Number 10
Steps to CKD Patient Care
creatinine
Glomerular filtration rate
Slide Number 14
Slide Number 15
Use These Equations Cautiously if at all in hellip
lab albumin creatinine ratio
The New CKD Categories
Steps to CKD Patient Care
Slide Number 20
Kidney Involvement in Systemic Diseases
Slide Number 22
Slide Number 23
DysmorphicRenal Hematuria
Slide Number 25
If you have albuminuria or hematuria-order the following labs
Additional Online Resources for CKD LearningbullNational Kidney Foundation wwwkidneyorgbullUnited States Renal Data Service wwwusrdsorgbullCDCrsquos CKD Surveillance Project
httpnccdcdcgovckdbullNational Kidney Disease Education Program
(NKDEP) httpnkdepnihgov
BIBLIOGRAPHY
bull Afzali B amp Goldsmith D J (2016 June 29) Statins and chronic kidney disease (G C Curhan amp A M Sheridan Eds) Retrieved 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsstatins-and-chronic-kidney-disease
bull American Diabetes Association Standards of Medical Care in Diabetes (2017) Microvascular complications and foot care Diabetes Care 2017 (40) S88-S98
bull American Diabetes Association Standards of Medical Care in Diabetes (2017) Microvascular complications and foot care Diabetes Care 40 (suppl 1) S88-S98
bull Berns J S (2017 Mar 22) Treatment of anemia in nondialysis chronic kidney disease (T A Golper amp A M Sheridan Eds) Retrieved from UpToDate httpswww-uptodate-comproxywichitaeducontentstreatment-of-anemia-in-nondialysis-chronic-kidney-disease
bull Chan M Dall A T Fletcher K E Lu N amp Trivedi H (2007) Outcomes in patients with chronic kidney disease referred late to nephrologists a meta-analysis American Journal of Medicine 120(12) 1063-1070
bull Coresh J Selvin E amp Stevens L A (2007) Prevalence of chronic kidny disease in the United States JAMA 298(17) doi101001jama298172038
bull de Brito-Ashurst I Varagunam M Raftery M amp Yagoob M (2009) Bicarbonate supplementation slows progression of CKD and improves nutritional status Journal of American Society of Nephrology (20) 2075-2084
BIBLIOGRAPHY
bull Duncan L Heathcoat J Djurdjev O amp Levin A (2001) Screening for renal disease using serum creatinine who are we missing Nephrology Dialysis and Transplant 16(5) 1042-1046
bull Dunkler D Gao P Lee S F Heinz G Clase C M Tobe S Oberbauer R (2015 August 7) Risk prediction for early CKD in type 2 diabetes Retrieved from Clinical Journal of the American Society of Nephrology httpcjasnasnjournalsorgcontent1081371fullsid=61422554-a5f1-41ac-b696-dcd3b12bd268
bull Fatehi P amp Chi-yuan H (September 15 2016) Diagnostic approach to the patient with newly identified chronic kidney disease (G C Curhan amp A M Sheridan Eds) Retrieved May 7 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsdiagnostic-approach-to-the-patient-with-newly-identified-chronic-kidney-disease
bull Fink J e (2009) Chronic Kidney Disease as an Under-Recognized Threat to Patient Safety American journal of kidney diseases the official journal of the National Kidney Foundation 53(4) 681-688
bull Gaffo A L amp Saag K G (2008 Nov) Management of hyperuricemia and gout in CKD doihttpdxdoiorg101053jajkd200807035
bull Hebert L A amp Parikh S V (2014 June 18) Differential diagnosis and evaluation of glomerular disease (R J Glassock amp A Q Lam Eds) Retrieved May 7 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsdifferential-diagnosis-and-evaluation-of-glomerular-disease
bull Inker L Perrone R D Sterns R H amp Forman J P (2017 March 7) Assessment of kidney function Retrieved from UpToDate httpswww-uptodate-comproxywichitaeducontentsassessment-of-kidney-functionsource=search_resultampsearch=creatinineampselectedTitle=1~150
BIBLIOGRAPHY
bull James P A Ortiz E amp Et Al (2014) Evidence based guideline for the management of high blood pressure in adults (JNC) JAMA 311(5) 507-520
bull Kidney Disease Improving Global Outcomes (KDIGO) CKD Work Group (2013 January) KDIGO 2012 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease Retrieved from Kidney International Supplement httpwwwkidney-internationalorg
bull Kunz R Friedrich C Wolbers M amp Mann J F (2008) Meta-analysis effect of monotherapy and combination therapy with inhibitors of the renin angiotensin system on proteinuria in renal disease Annals of Internal Medicine 148(1) 30-48
bull Levey A Stevens L A Schmid C H Castro A F Feldman H I Kusek J W Coresh J (2009) A new equation to estimate glomerular filtration rate Annals of Internal Medicine 150(9) 604-612
bull Levin A Bakris G L Molitch M Smulders M M Williams L A amp Andress D L (2007 Jan) Prevalence of abnormal serum vitamin D PTH calcium and phosphorus in patients with chronic kidney disease results of the study to evaluate early kidney disease Kidney International 71(1) 31-38 Retrieved from PubMED
bull Mahajan A Simoni J Sheather S Broglio K Rajab M amp Wesson D (2010) Daily oral sodium bicarbonate preserves glomerular filtration rate by slowing its decline in early hypertensive nephropathy Kidney International (78_ 303-309
bull Mann J Schmieder R E amp McQueen M (2008) Renal outcomes with telmisartan ramipril or both in people at high vascular risk (the ONTARGET study) a multicentre randomised doubleblind ocntrolled trial Lancet 372(9638) 547-533
BIBLIOGRAPHY
bull Matovinović M S (2009) Pathophysiology and classification of kidney disease Retrieved from The Journal of the International Federation of Clinical Chemistry and Laboratory Medicine httpwwwifccorgifccfilesdocs20010902pdf
bull Moe S Drueke T Lameire N amp Eknoyan G (2007 Jan) Chronic kidney disease-mineral-bone disorder a new paradigmdoi101053jackd200610005
bull Murtagh F E Marsh J E Donohoe P Ekbal N J Sheerin N S amp Harris F E (2007 July) Dialysis or not A comparative survival study of patients over 75 years with chronic kidney disease stage 5 Retrieved from Nephrology Dialysis and Transplant 22(7) httpswwwncbinlmnihgovpubmed17412702
bull National Kidney Foundation (2002) KDOQI clinical practice guidelines for chronic kidney disease evaluation classification andstratification American Journal of Kidney Disease S1-S266
bull National Kidney Foundation (2014 November 5) Fact Sheets Retrieved from httpwwwkidneyorgnewsnewsroomfactsheetsFastFacts
bull Pal S (2012 June 2) Trends in chronic kidney disease Retrieved from US Pharmacist (37)6 httpswwwuspharmacistcomarticletrends-in-chronic-kidney-disease
bull Qunibi W amp Henrich W L (2017 Jan 19) Overview of chronic kidney disease-mineral and bone disorder (J Berns amp A M Sheridan Eds) Retrieved from UpToDate httpswww-uptodate-comoverview-of-chronic-kidney-disease-mineral-and-bone-disorder-ckd-mbd
bull Rosenberg M (2016 Feb 24) Overview of the management of chronic kidney disease in adults (G C Curhan amp A M Sheridan Eds) Retrieved from UpToDate UpToDate httpswww-uptodate-comproxywichitaeducontentsoverview-of-the-management-of-chronic-kidney-disease-in-adults
BIBLIOGRAPHY
bull Szczech L Stewart R C Hsu-Lin S DeLosky R J Astor B C Fox C H Vassalotti J A (2014) Primary care detection of chronic kidney disease in adults with type 2 diabetes The ADD-CKD Study (Awareness Detection and Drug Therapy in type 2 diabetes and chronic kidney disease PLOS doihttpsdoiorg101371journalpone0110535
bull USRDS (2016) Annual data report 2016 Epidemiology of kidney disease in the United States Retrieved from United States Renal Data System httpswwwusrdsorgadraspx
bull Vasudev B amp Vasudev M (2012) A model curriculum for residents rotating in nephrology MedEDPORTAL doihttpdoiorg1015766mep_2374-82658288
bull Wei L MacDonald T M Jennings C Sheng X amp Flynn R W (2013) Estimated GFR reporting is associated with decreased nonsteroidal anti-inflammatory drug prescribing and increased renal function Kidney International (84)1 174-178
chronic kidney disease in primary care
CKD as a Public Health Issue
Slide Number 3
Costs of CKD in 2013 dollarsUSRDS report
Steps to CKD Patient Care
Renal anatomy and physiology
Definition of Chronic Kidney Disease
CKD Risk Factors
Gaps in CKD Diagnosis
Slide Number 10
Steps to CKD Patient Care
creatinine
Glomerular filtration rate
Slide Number 14
Slide Number 15
Use These Equations Cautiously if at all in hellip
lab albumin creatinine ratio
The New CKD Categories
Steps to CKD Patient Care
Slide Number 20
Kidney Involvement in Systemic Diseases
Slide Number 22
Slide Number 23
DysmorphicRenal Hematuria
Slide Number 25
If you have albuminuria or hematuria-order the following labs
Prevalence of Abnormalities of Mineral Metabolism PTH in CKD
Managing CKD-MBD complications
CKD-MBD Testing
Anemia Becomes More Common as Kidney Function Declines
Detect and Manage CKD Complications
Complications-metabolic acidosis
Complications-vascular calcification
Hyperkalemia management
Hyperuricemia levels amp CKD
CKD monitoring levels 345
Slide Number 59
When to Refer to a Nephrologist
When to Refer
Steps to CKD Patient Care
Kidney transplantation
Starting Dialysis in the ElderlyhellipOr Not
Ckd management
Case 1
Slide Number 67
Lab results
Slide Number 69
Hypertensive nephropathy with proteinuria
Slide Number 71
Case 2
Slide Number 73
Management of CKD in Diabetes
Case 3
Case 3
Systemic Lupus Erythematosus (SLE)
SLE ndash Lupus Nephritis
Case 5
Case 5
Slide Number 81
Slide Number 82
Case study
Slide Number 84
CXR ndash Hilar Lymphadenopathy
Whats needed next
Slide Number 87
newly dx ckd
Slide Number 89
Bibliography
bibliography
bibliography
bibliography
bibliography
Additional Online Resources for CKD LearningbullNational Kidney Foundation wwwkidneyorgbullUnited States Renal Data Service wwwusrdsorgbullCDCrsquos CKD Surveillance Project
httpnccdcdcgovckdbullNational Kidney Disease Education Program
(NKDEP) httpnkdepnihgov
BIBLIOGRAPHY
bull Afzali B amp Goldsmith D J (2016 June 29) Statins and chronic kidney disease (G C Curhan amp A M Sheridan Eds) Retrieved 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsstatins-and-chronic-kidney-disease
bull American Diabetes Association Standards of Medical Care in Diabetes (2017) Microvascular complications and foot care Diabetes Care 2017 (40) S88-S98
bull American Diabetes Association Standards of Medical Care in Diabetes (2017) Microvascular complications and foot care Diabetes Care 40 (suppl 1) S88-S98
bull Berns J S (2017 Mar 22) Treatment of anemia in nondialysis chronic kidney disease (T A Golper amp A M Sheridan Eds) Retrieved from UpToDate httpswww-uptodate-comproxywichitaeducontentstreatment-of-anemia-in-nondialysis-chronic-kidney-disease
bull Chan M Dall A T Fletcher K E Lu N amp Trivedi H (2007) Outcomes in patients with chronic kidney disease referred late to nephrologists a meta-analysis American Journal of Medicine 120(12) 1063-1070
bull Coresh J Selvin E amp Stevens L A (2007) Prevalence of chronic kidny disease in the United States JAMA 298(17) doi101001jama298172038
bull de Brito-Ashurst I Varagunam M Raftery M amp Yagoob M (2009) Bicarbonate supplementation slows progression of CKD and improves nutritional status Journal of American Society of Nephrology (20) 2075-2084
BIBLIOGRAPHY
bull Duncan L Heathcoat J Djurdjev O amp Levin A (2001) Screening for renal disease using serum creatinine who are we missing Nephrology Dialysis and Transplant 16(5) 1042-1046
bull Dunkler D Gao P Lee S F Heinz G Clase C M Tobe S Oberbauer R (2015 August 7) Risk prediction for early CKD in type 2 diabetes Retrieved from Clinical Journal of the American Society of Nephrology httpcjasnasnjournalsorgcontent1081371fullsid=61422554-a5f1-41ac-b696-dcd3b12bd268
bull Fatehi P amp Chi-yuan H (September 15 2016) Diagnostic approach to the patient with newly identified chronic kidney disease (G C Curhan amp A M Sheridan Eds) Retrieved May 7 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsdiagnostic-approach-to-the-patient-with-newly-identified-chronic-kidney-disease
bull Fink J e (2009) Chronic Kidney Disease as an Under-Recognized Threat to Patient Safety American journal of kidney diseases the official journal of the National Kidney Foundation 53(4) 681-688
bull Gaffo A L amp Saag K G (2008 Nov) Management of hyperuricemia and gout in CKD doihttpdxdoiorg101053jajkd200807035
bull Hebert L A amp Parikh S V (2014 June 18) Differential diagnosis and evaluation of glomerular disease (R J Glassock amp A Q Lam Eds) Retrieved May 7 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsdifferential-diagnosis-and-evaluation-of-glomerular-disease
bull Inker L Perrone R D Sterns R H amp Forman J P (2017 March 7) Assessment of kidney function Retrieved from UpToDate httpswww-uptodate-comproxywichitaeducontentsassessment-of-kidney-functionsource=search_resultampsearch=creatinineampselectedTitle=1~150
BIBLIOGRAPHY
bull James P A Ortiz E amp Et Al (2014) Evidence based guideline for the management of high blood pressure in adults (JNC) JAMA 311(5) 507-520
bull Kidney Disease Improving Global Outcomes (KDIGO) CKD Work Group (2013 January) KDIGO 2012 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease Retrieved from Kidney International Supplement httpwwwkidney-internationalorg
bull Kunz R Friedrich C Wolbers M amp Mann J F (2008) Meta-analysis effect of monotherapy and combination therapy with inhibitors of the renin angiotensin system on proteinuria in renal disease Annals of Internal Medicine 148(1) 30-48
bull Levey A Stevens L A Schmid C H Castro A F Feldman H I Kusek J W Coresh J (2009) A new equation to estimate glomerular filtration rate Annals of Internal Medicine 150(9) 604-612
bull Levin A Bakris G L Molitch M Smulders M M Williams L A amp Andress D L (2007 Jan) Prevalence of abnormal serum vitamin D PTH calcium and phosphorus in patients with chronic kidney disease results of the study to evaluate early kidney disease Kidney International 71(1) 31-38 Retrieved from PubMED
bull Mahajan A Simoni J Sheather S Broglio K Rajab M amp Wesson D (2010) Daily oral sodium bicarbonate preserves glomerular filtration rate by slowing its decline in early hypertensive nephropathy Kidney International (78_ 303-309
bull Mann J Schmieder R E amp McQueen M (2008) Renal outcomes with telmisartan ramipril or both in people at high vascular risk (the ONTARGET study) a multicentre randomised doubleblind ocntrolled trial Lancet 372(9638) 547-533
BIBLIOGRAPHY
bull Matovinović M S (2009) Pathophysiology and classification of kidney disease Retrieved from The Journal of the International Federation of Clinical Chemistry and Laboratory Medicine httpwwwifccorgifccfilesdocs20010902pdf
bull Moe S Drueke T Lameire N amp Eknoyan G (2007 Jan) Chronic kidney disease-mineral-bone disorder a new paradigmdoi101053jackd200610005
bull Murtagh F E Marsh J E Donohoe P Ekbal N J Sheerin N S amp Harris F E (2007 July) Dialysis or not A comparative survival study of patients over 75 years with chronic kidney disease stage 5 Retrieved from Nephrology Dialysis and Transplant 22(7) httpswwwncbinlmnihgovpubmed17412702
bull National Kidney Foundation (2002) KDOQI clinical practice guidelines for chronic kidney disease evaluation classification andstratification American Journal of Kidney Disease S1-S266
bull National Kidney Foundation (2014 November 5) Fact Sheets Retrieved from httpwwwkidneyorgnewsnewsroomfactsheetsFastFacts
bull Pal S (2012 June 2) Trends in chronic kidney disease Retrieved from US Pharmacist (37)6 httpswwwuspharmacistcomarticletrends-in-chronic-kidney-disease
bull Qunibi W amp Henrich W L (2017 Jan 19) Overview of chronic kidney disease-mineral and bone disorder (J Berns amp A M Sheridan Eds) Retrieved from UpToDate httpswww-uptodate-comoverview-of-chronic-kidney-disease-mineral-and-bone-disorder-ckd-mbd
bull Rosenberg M (2016 Feb 24) Overview of the management of chronic kidney disease in adults (G C Curhan amp A M Sheridan Eds) Retrieved from UpToDate UpToDate httpswww-uptodate-comproxywichitaeducontentsoverview-of-the-management-of-chronic-kidney-disease-in-adults
BIBLIOGRAPHY
bull Szczech L Stewart R C Hsu-Lin S DeLosky R J Astor B C Fox C H Vassalotti J A (2014) Primary care detection of chronic kidney disease in adults with type 2 diabetes The ADD-CKD Study (Awareness Detection and Drug Therapy in type 2 diabetes and chronic kidney disease PLOS doihttpsdoiorg101371journalpone0110535
bull USRDS (2016) Annual data report 2016 Epidemiology of kidney disease in the United States Retrieved from United States Renal Data System httpswwwusrdsorgadraspx
bull Vasudev B amp Vasudev M (2012) A model curriculum for residents rotating in nephrology MedEDPORTAL doihttpdoiorg1015766mep_2374-82658288
bull Wei L MacDonald T M Jennings C Sheng X amp Flynn R W (2013) Estimated GFR reporting is associated with decreased nonsteroidal anti-inflammatory drug prescribing and increased renal function Kidney International (84)1 174-178
chronic kidney disease in primary care
CKD as a Public Health Issue
Slide Number 3
Costs of CKD in 2013 dollarsUSRDS report
Steps to CKD Patient Care
Renal anatomy and physiology
Definition of Chronic Kidney Disease
CKD Risk Factors
Gaps in CKD Diagnosis
Slide Number 10
Steps to CKD Patient Care
creatinine
Glomerular filtration rate
Slide Number 14
Slide Number 15
Use These Equations Cautiously if at all in hellip
lab albumin creatinine ratio
The New CKD Categories
Steps to CKD Patient Care
Slide Number 20
Kidney Involvement in Systemic Diseases
Slide Number 22
Slide Number 23
DysmorphicRenal Hematuria
Slide Number 25
If you have albuminuria or hematuria-order the following labs
Prevalence of Abnormalities of Mineral Metabolism PTH in CKD
Managing CKD-MBD complications
CKD-MBD Testing
Anemia Becomes More Common as Kidney Function Declines
Detect and Manage CKD Complications
Complications-metabolic acidosis
Complications-vascular calcification
Hyperkalemia management
Hyperuricemia levels amp CKD
CKD monitoring levels 345
Slide Number 59
When to Refer to a Nephrologist
When to Refer
Steps to CKD Patient Care
Kidney transplantation
Starting Dialysis in the ElderlyhellipOr Not
Ckd management
Case 1
Slide Number 67
Lab results
Slide Number 69
Hypertensive nephropathy with proteinuria
Slide Number 71
Case 2
Slide Number 73
Management of CKD in Diabetes
Case 3
Case 3
Systemic Lupus Erythematosus (SLE)
SLE ndash Lupus Nephritis
Case 5
Case 5
Slide Number 81
Slide Number 82
Case study
Slide Number 84
CXR ndash Hilar Lymphadenopathy
Whats needed next
Slide Number 87
newly dx ckd
Slide Number 89
Bibliography
bibliography
bibliography
bibliography
bibliography
BIBLIOGRAPHY
bull Afzali B amp Goldsmith D J (2016 June 29) Statins and chronic kidney disease (G C Curhan amp A M Sheridan Eds) Retrieved 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsstatins-and-chronic-kidney-disease
bull American Diabetes Association Standards of Medical Care in Diabetes (2017) Microvascular complications and foot care Diabetes Care 2017 (40) S88-S98
bull American Diabetes Association Standards of Medical Care in Diabetes (2017) Microvascular complications and foot care Diabetes Care 40 (suppl 1) S88-S98
bull Berns J S (2017 Mar 22) Treatment of anemia in nondialysis chronic kidney disease (T A Golper amp A M Sheridan Eds) Retrieved from UpToDate httpswww-uptodate-comproxywichitaeducontentstreatment-of-anemia-in-nondialysis-chronic-kidney-disease
bull Chan M Dall A T Fletcher K E Lu N amp Trivedi H (2007) Outcomes in patients with chronic kidney disease referred late to nephrologists a meta-analysis American Journal of Medicine 120(12) 1063-1070
bull Coresh J Selvin E amp Stevens L A (2007) Prevalence of chronic kidny disease in the United States JAMA 298(17) doi101001jama298172038
bull de Brito-Ashurst I Varagunam M Raftery M amp Yagoob M (2009) Bicarbonate supplementation slows progression of CKD and improves nutritional status Journal of American Society of Nephrology (20) 2075-2084
BIBLIOGRAPHY
bull Duncan L Heathcoat J Djurdjev O amp Levin A (2001) Screening for renal disease using serum creatinine who are we missing Nephrology Dialysis and Transplant 16(5) 1042-1046
bull Dunkler D Gao P Lee S F Heinz G Clase C M Tobe S Oberbauer R (2015 August 7) Risk prediction for early CKD in type 2 diabetes Retrieved from Clinical Journal of the American Society of Nephrology httpcjasnasnjournalsorgcontent1081371fullsid=61422554-a5f1-41ac-b696-dcd3b12bd268
bull Fatehi P amp Chi-yuan H (September 15 2016) Diagnostic approach to the patient with newly identified chronic kidney disease (G C Curhan amp A M Sheridan Eds) Retrieved May 7 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsdiagnostic-approach-to-the-patient-with-newly-identified-chronic-kidney-disease
bull Fink J e (2009) Chronic Kidney Disease as an Under-Recognized Threat to Patient Safety American journal of kidney diseases the official journal of the National Kidney Foundation 53(4) 681-688
bull Gaffo A L amp Saag K G (2008 Nov) Management of hyperuricemia and gout in CKD doihttpdxdoiorg101053jajkd200807035
bull Hebert L A amp Parikh S V (2014 June 18) Differential diagnosis and evaluation of glomerular disease (R J Glassock amp A Q Lam Eds) Retrieved May 7 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsdifferential-diagnosis-and-evaluation-of-glomerular-disease
bull Inker L Perrone R D Sterns R H amp Forman J P (2017 March 7) Assessment of kidney function Retrieved from UpToDate httpswww-uptodate-comproxywichitaeducontentsassessment-of-kidney-functionsource=search_resultampsearch=creatinineampselectedTitle=1~150
BIBLIOGRAPHY
bull James P A Ortiz E amp Et Al (2014) Evidence based guideline for the management of high blood pressure in adults (JNC) JAMA 311(5) 507-520
bull Kidney Disease Improving Global Outcomes (KDIGO) CKD Work Group (2013 January) KDIGO 2012 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease Retrieved from Kidney International Supplement httpwwwkidney-internationalorg
bull Kunz R Friedrich C Wolbers M amp Mann J F (2008) Meta-analysis effect of monotherapy and combination therapy with inhibitors of the renin angiotensin system on proteinuria in renal disease Annals of Internal Medicine 148(1) 30-48
bull Levey A Stevens L A Schmid C H Castro A F Feldman H I Kusek J W Coresh J (2009) A new equation to estimate glomerular filtration rate Annals of Internal Medicine 150(9) 604-612
bull Levin A Bakris G L Molitch M Smulders M M Williams L A amp Andress D L (2007 Jan) Prevalence of abnormal serum vitamin D PTH calcium and phosphorus in patients with chronic kidney disease results of the study to evaluate early kidney disease Kidney International 71(1) 31-38 Retrieved from PubMED
bull Mahajan A Simoni J Sheather S Broglio K Rajab M amp Wesson D (2010) Daily oral sodium bicarbonate preserves glomerular filtration rate by slowing its decline in early hypertensive nephropathy Kidney International (78_ 303-309
bull Mann J Schmieder R E amp McQueen M (2008) Renal outcomes with telmisartan ramipril or both in people at high vascular risk (the ONTARGET study) a multicentre randomised doubleblind ocntrolled trial Lancet 372(9638) 547-533
BIBLIOGRAPHY
bull Matovinović M S (2009) Pathophysiology and classification of kidney disease Retrieved from The Journal of the International Federation of Clinical Chemistry and Laboratory Medicine httpwwwifccorgifccfilesdocs20010902pdf
bull Moe S Drueke T Lameire N amp Eknoyan G (2007 Jan) Chronic kidney disease-mineral-bone disorder a new paradigmdoi101053jackd200610005
bull Murtagh F E Marsh J E Donohoe P Ekbal N J Sheerin N S amp Harris F E (2007 July) Dialysis or not A comparative survival study of patients over 75 years with chronic kidney disease stage 5 Retrieved from Nephrology Dialysis and Transplant 22(7) httpswwwncbinlmnihgovpubmed17412702
bull National Kidney Foundation (2002) KDOQI clinical practice guidelines for chronic kidney disease evaluation classification andstratification American Journal of Kidney Disease S1-S266
bull National Kidney Foundation (2014 November 5) Fact Sheets Retrieved from httpwwwkidneyorgnewsnewsroomfactsheetsFastFacts
bull Pal S (2012 June 2) Trends in chronic kidney disease Retrieved from US Pharmacist (37)6 httpswwwuspharmacistcomarticletrends-in-chronic-kidney-disease
bull Qunibi W amp Henrich W L (2017 Jan 19) Overview of chronic kidney disease-mineral and bone disorder (J Berns amp A M Sheridan Eds) Retrieved from UpToDate httpswww-uptodate-comoverview-of-chronic-kidney-disease-mineral-and-bone-disorder-ckd-mbd
bull Rosenberg M (2016 Feb 24) Overview of the management of chronic kidney disease in adults (G C Curhan amp A M Sheridan Eds) Retrieved from UpToDate UpToDate httpswww-uptodate-comproxywichitaeducontentsoverview-of-the-management-of-chronic-kidney-disease-in-adults
BIBLIOGRAPHY
bull Szczech L Stewart R C Hsu-Lin S DeLosky R J Astor B C Fox C H Vassalotti J A (2014) Primary care detection of chronic kidney disease in adults with type 2 diabetes The ADD-CKD Study (Awareness Detection and Drug Therapy in type 2 diabetes and chronic kidney disease PLOS doihttpsdoiorg101371journalpone0110535
bull USRDS (2016) Annual data report 2016 Epidemiology of kidney disease in the United States Retrieved from United States Renal Data System httpswwwusrdsorgadraspx
bull Vasudev B amp Vasudev M (2012) A model curriculum for residents rotating in nephrology MedEDPORTAL doihttpdoiorg1015766mep_2374-82658288
bull Wei L MacDonald T M Jennings C Sheng X amp Flynn R W (2013) Estimated GFR reporting is associated with decreased nonsteroidal anti-inflammatory drug prescribing and increased renal function Kidney International (84)1 174-178
chronic kidney disease in primary care
CKD as a Public Health Issue
Slide Number 3
Costs of CKD in 2013 dollarsUSRDS report
Steps to CKD Patient Care
Renal anatomy and physiology
Definition of Chronic Kidney Disease
CKD Risk Factors
Gaps in CKD Diagnosis
Slide Number 10
Steps to CKD Patient Care
creatinine
Glomerular filtration rate
Slide Number 14
Slide Number 15
Use These Equations Cautiously if at all in hellip
lab albumin creatinine ratio
The New CKD Categories
Steps to CKD Patient Care
Slide Number 20
Kidney Involvement in Systemic Diseases
Slide Number 22
Slide Number 23
DysmorphicRenal Hematuria
Slide Number 25
If you have albuminuria or hematuria-order the following labs
Prevalence of Abnormalities of Mineral Metabolism PTH in CKD
Managing CKD-MBD complications
CKD-MBD Testing
Anemia Becomes More Common as Kidney Function Declines
Detect and Manage CKD Complications
Complications-metabolic acidosis
Complications-vascular calcification
Hyperkalemia management
Hyperuricemia levels amp CKD
CKD monitoring levels 345
Slide Number 59
When to Refer to a Nephrologist
When to Refer
Steps to CKD Patient Care
Kidney transplantation
Starting Dialysis in the ElderlyhellipOr Not
Ckd management
Case 1
Slide Number 67
Lab results
Slide Number 69
Hypertensive nephropathy with proteinuria
Slide Number 71
Case 2
Slide Number 73
Management of CKD in Diabetes
Case 3
Case 3
Systemic Lupus Erythematosus (SLE)
SLE ndash Lupus Nephritis
Case 5
Case 5
Slide Number 81
Slide Number 82
Case study
Slide Number 84
CXR ndash Hilar Lymphadenopathy
Whats needed next
Slide Number 87
newly dx ckd
Slide Number 89
Bibliography
bibliography
bibliography
bibliography
bibliography
BIBLIOGRAPHY
bull Duncan L Heathcoat J Djurdjev O amp Levin A (2001) Screening for renal disease using serum creatinine who are we missing Nephrology Dialysis and Transplant 16(5) 1042-1046
bull Dunkler D Gao P Lee S F Heinz G Clase C M Tobe S Oberbauer R (2015 August 7) Risk prediction for early CKD in type 2 diabetes Retrieved from Clinical Journal of the American Society of Nephrology httpcjasnasnjournalsorgcontent1081371fullsid=61422554-a5f1-41ac-b696-dcd3b12bd268
bull Fatehi P amp Chi-yuan H (September 15 2016) Diagnostic approach to the patient with newly identified chronic kidney disease (G C Curhan amp A M Sheridan Eds) Retrieved May 7 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsdiagnostic-approach-to-the-patient-with-newly-identified-chronic-kidney-disease
bull Fink J e (2009) Chronic Kidney Disease as an Under-Recognized Threat to Patient Safety American journal of kidney diseases the official journal of the National Kidney Foundation 53(4) 681-688
bull Gaffo A L amp Saag K G (2008 Nov) Management of hyperuricemia and gout in CKD doihttpdxdoiorg101053jajkd200807035
bull Hebert L A amp Parikh S V (2014 June 18) Differential diagnosis and evaluation of glomerular disease (R J Glassock amp A Q Lam Eds) Retrieved May 7 2017 from UpToDate httpswww-uptodate-comproxywichitaeducontentsdifferential-diagnosis-and-evaluation-of-glomerular-disease
bull Inker L Perrone R D Sterns R H amp Forman J P (2017 March 7) Assessment of kidney function Retrieved from UpToDate httpswww-uptodate-comproxywichitaeducontentsassessment-of-kidney-functionsource=search_resultampsearch=creatinineampselectedTitle=1~150
BIBLIOGRAPHY
bull James P A Ortiz E amp Et Al (2014) Evidence based guideline for the management of high blood pressure in adults (JNC) JAMA 311(5) 507-520
bull Kidney Disease Improving Global Outcomes (KDIGO) CKD Work Group (2013 January) KDIGO 2012 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease Retrieved from Kidney International Supplement httpwwwkidney-internationalorg
bull Kunz R Friedrich C Wolbers M amp Mann J F (2008) Meta-analysis effect of monotherapy and combination therapy with inhibitors of the renin angiotensin system on proteinuria in renal disease Annals of Internal Medicine 148(1) 30-48
bull Levey A Stevens L A Schmid C H Castro A F Feldman H I Kusek J W Coresh J (2009) A new equation to estimate glomerular filtration rate Annals of Internal Medicine 150(9) 604-612
bull Levin A Bakris G L Molitch M Smulders M M Williams L A amp Andress D L (2007 Jan) Prevalence of abnormal serum vitamin D PTH calcium and phosphorus in patients with chronic kidney disease results of the study to evaluate early kidney disease Kidney International 71(1) 31-38 Retrieved from PubMED
bull Mahajan A Simoni J Sheather S Broglio K Rajab M amp Wesson D (2010) Daily oral sodium bicarbonate preserves glomerular filtration rate by slowing its decline in early hypertensive nephropathy Kidney International (78_ 303-309
bull Mann J Schmieder R E amp McQueen M (2008) Renal outcomes with telmisartan ramipril or both in people at high vascular risk (the ONTARGET study) a multicentre randomised doubleblind ocntrolled trial Lancet 372(9638) 547-533
BIBLIOGRAPHY
bull Matovinović M S (2009) Pathophysiology and classification of kidney disease Retrieved from The Journal of the International Federation of Clinical Chemistry and Laboratory Medicine httpwwwifccorgifccfilesdocs20010902pdf
bull Moe S Drueke T Lameire N amp Eknoyan G (2007 Jan) Chronic kidney disease-mineral-bone disorder a new paradigmdoi101053jackd200610005
bull Murtagh F E Marsh J E Donohoe P Ekbal N J Sheerin N S amp Harris F E (2007 July) Dialysis or not A comparative survival study of patients over 75 years with chronic kidney disease stage 5 Retrieved from Nephrology Dialysis and Transplant 22(7) httpswwwncbinlmnihgovpubmed17412702
bull National Kidney Foundation (2002) KDOQI clinical practice guidelines for chronic kidney disease evaluation classification andstratification American Journal of Kidney Disease S1-S266
bull National Kidney Foundation (2014 November 5) Fact Sheets Retrieved from httpwwwkidneyorgnewsnewsroomfactsheetsFastFacts
bull Pal S (2012 June 2) Trends in chronic kidney disease Retrieved from US Pharmacist (37)6 httpswwwuspharmacistcomarticletrends-in-chronic-kidney-disease
bull Qunibi W amp Henrich W L (2017 Jan 19) Overview of chronic kidney disease-mineral and bone disorder (J Berns amp A M Sheridan Eds) Retrieved from UpToDate httpswww-uptodate-comoverview-of-chronic-kidney-disease-mineral-and-bone-disorder-ckd-mbd
bull Rosenberg M (2016 Feb 24) Overview of the management of chronic kidney disease in adults (G C Curhan amp A M Sheridan Eds) Retrieved from UpToDate UpToDate httpswww-uptodate-comproxywichitaeducontentsoverview-of-the-management-of-chronic-kidney-disease-in-adults
BIBLIOGRAPHY
bull Szczech L Stewart R C Hsu-Lin S DeLosky R J Astor B C Fox C H Vassalotti J A (2014) Primary care detection of chronic kidney disease in adults with type 2 diabetes The ADD-CKD Study (Awareness Detection and Drug Therapy in type 2 diabetes and chronic kidney disease PLOS doihttpsdoiorg101371journalpone0110535
bull USRDS (2016) Annual data report 2016 Epidemiology of kidney disease in the United States Retrieved from United States Renal Data System httpswwwusrdsorgadraspx
bull Vasudev B amp Vasudev M (2012) A model curriculum for residents rotating in nephrology MedEDPORTAL doihttpdoiorg1015766mep_2374-82658288
bull Wei L MacDonald T M Jennings C Sheng X amp Flynn R W (2013) Estimated GFR reporting is associated with decreased nonsteroidal anti-inflammatory drug prescribing and increased renal function Kidney International (84)1 174-178
chronic kidney disease in primary care
CKD as a Public Health Issue
Slide Number 3
Costs of CKD in 2013 dollarsUSRDS report
Steps to CKD Patient Care
Renal anatomy and physiology
Definition of Chronic Kidney Disease
CKD Risk Factors
Gaps in CKD Diagnosis
Slide Number 10
Steps to CKD Patient Care
creatinine
Glomerular filtration rate
Slide Number 14
Slide Number 15
Use These Equations Cautiously if at all in hellip
lab albumin creatinine ratio
The New CKD Categories
Steps to CKD Patient Care
Slide Number 20
Kidney Involvement in Systemic Diseases
Slide Number 22
Slide Number 23
DysmorphicRenal Hematuria
Slide Number 25
If you have albuminuria or hematuria-order the following labs
Prevalence of Abnormalities of Mineral Metabolism PTH in CKD
Managing CKD-MBD complications
CKD-MBD Testing
Anemia Becomes More Common as Kidney Function Declines
Detect and Manage CKD Complications
Complications-metabolic acidosis
Complications-vascular calcification
Hyperkalemia management
Hyperuricemia levels amp CKD
CKD monitoring levels 345
Slide Number 59
When to Refer to a Nephrologist
When to Refer
Steps to CKD Patient Care
Kidney transplantation
Starting Dialysis in the ElderlyhellipOr Not
Ckd management
Case 1
Slide Number 67
Lab results
Slide Number 69
Hypertensive nephropathy with proteinuria
Slide Number 71
Case 2
Slide Number 73
Management of CKD in Diabetes
Case 3
Case 3
Systemic Lupus Erythematosus (SLE)
SLE ndash Lupus Nephritis
Case 5
Case 5
Slide Number 81
Slide Number 82
Case study
Slide Number 84
CXR ndash Hilar Lymphadenopathy
Whats needed next
Slide Number 87
newly dx ckd
Slide Number 89
Bibliography
bibliography
bibliography
bibliography
bibliography
BIBLIOGRAPHY
bull James P A Ortiz E amp Et Al (2014) Evidence based guideline for the management of high blood pressure in adults (JNC) JAMA 311(5) 507-520
bull Kidney Disease Improving Global Outcomes (KDIGO) CKD Work Group (2013 January) KDIGO 2012 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease Retrieved from Kidney International Supplement httpwwwkidney-internationalorg
bull Kunz R Friedrich C Wolbers M amp Mann J F (2008) Meta-analysis effect of monotherapy and combination therapy with inhibitors of the renin angiotensin system on proteinuria in renal disease Annals of Internal Medicine 148(1) 30-48
bull Levey A Stevens L A Schmid C H Castro A F Feldman H I Kusek J W Coresh J (2009) A new equation to estimate glomerular filtration rate Annals of Internal Medicine 150(9) 604-612
bull Levin A Bakris G L Molitch M Smulders M M Williams L A amp Andress D L (2007 Jan) Prevalence of abnormal serum vitamin D PTH calcium and phosphorus in patients with chronic kidney disease results of the study to evaluate early kidney disease Kidney International 71(1) 31-38 Retrieved from PubMED
bull Mahajan A Simoni J Sheather S Broglio K Rajab M amp Wesson D (2010) Daily oral sodium bicarbonate preserves glomerular filtration rate by slowing its decline in early hypertensive nephropathy Kidney International (78_ 303-309
bull Mann J Schmieder R E amp McQueen M (2008) Renal outcomes with telmisartan ramipril or both in people at high vascular risk (the ONTARGET study) a multicentre randomised doubleblind ocntrolled trial Lancet 372(9638) 547-533
BIBLIOGRAPHY
bull Matovinović M S (2009) Pathophysiology and classification of kidney disease Retrieved from The Journal of the International Federation of Clinical Chemistry and Laboratory Medicine httpwwwifccorgifccfilesdocs20010902pdf
bull Moe S Drueke T Lameire N amp Eknoyan G (2007 Jan) Chronic kidney disease-mineral-bone disorder a new paradigmdoi101053jackd200610005
bull Murtagh F E Marsh J E Donohoe P Ekbal N J Sheerin N S amp Harris F E (2007 July) Dialysis or not A comparative survival study of patients over 75 years with chronic kidney disease stage 5 Retrieved from Nephrology Dialysis and Transplant 22(7) httpswwwncbinlmnihgovpubmed17412702
bull National Kidney Foundation (2002) KDOQI clinical practice guidelines for chronic kidney disease evaluation classification andstratification American Journal of Kidney Disease S1-S266
bull National Kidney Foundation (2014 November 5) Fact Sheets Retrieved from httpwwwkidneyorgnewsnewsroomfactsheetsFastFacts
bull Pal S (2012 June 2) Trends in chronic kidney disease Retrieved from US Pharmacist (37)6 httpswwwuspharmacistcomarticletrends-in-chronic-kidney-disease
bull Qunibi W amp Henrich W L (2017 Jan 19) Overview of chronic kidney disease-mineral and bone disorder (J Berns amp A M Sheridan Eds) Retrieved from UpToDate httpswww-uptodate-comoverview-of-chronic-kidney-disease-mineral-and-bone-disorder-ckd-mbd
bull Rosenberg M (2016 Feb 24) Overview of the management of chronic kidney disease in adults (G C Curhan amp A M Sheridan Eds) Retrieved from UpToDate UpToDate httpswww-uptodate-comproxywichitaeducontentsoverview-of-the-management-of-chronic-kidney-disease-in-adults
BIBLIOGRAPHY
bull Szczech L Stewart R C Hsu-Lin S DeLosky R J Astor B C Fox C H Vassalotti J A (2014) Primary care detection of chronic kidney disease in adults with type 2 diabetes The ADD-CKD Study (Awareness Detection and Drug Therapy in type 2 diabetes and chronic kidney disease PLOS doihttpsdoiorg101371journalpone0110535
bull USRDS (2016) Annual data report 2016 Epidemiology of kidney disease in the United States Retrieved from United States Renal Data System httpswwwusrdsorgadraspx
bull Vasudev B amp Vasudev M (2012) A model curriculum for residents rotating in nephrology MedEDPORTAL doihttpdoiorg1015766mep_2374-82658288
bull Wei L MacDonald T M Jennings C Sheng X amp Flynn R W (2013) Estimated GFR reporting is associated with decreased nonsteroidal anti-inflammatory drug prescribing and increased renal function Kidney International (84)1 174-178
chronic kidney disease in primary care
CKD as a Public Health Issue
Slide Number 3
Costs of CKD in 2013 dollarsUSRDS report
Steps to CKD Patient Care
Renal anatomy and physiology
Definition of Chronic Kidney Disease
CKD Risk Factors
Gaps in CKD Diagnosis
Slide Number 10
Steps to CKD Patient Care
creatinine
Glomerular filtration rate
Slide Number 14
Slide Number 15
Use These Equations Cautiously if at all in hellip
lab albumin creatinine ratio
The New CKD Categories
Steps to CKD Patient Care
Slide Number 20
Kidney Involvement in Systemic Diseases
Slide Number 22
Slide Number 23
DysmorphicRenal Hematuria
Slide Number 25
If you have albuminuria or hematuria-order the following labs
Prevalence of Abnormalities of Mineral Metabolism PTH in CKD
Managing CKD-MBD complications
CKD-MBD Testing
Anemia Becomes More Common as Kidney Function Declines
Detect and Manage CKD Complications
Complications-metabolic acidosis
Complications-vascular calcification
Hyperkalemia management
Hyperuricemia levels amp CKD
CKD monitoring levels 345
Slide Number 59
When to Refer to a Nephrologist
When to Refer
Steps to CKD Patient Care
Kidney transplantation
Starting Dialysis in the ElderlyhellipOr Not
Ckd management
Case 1
Slide Number 67
Lab results
Slide Number 69
Hypertensive nephropathy with proteinuria
Slide Number 71
Case 2
Slide Number 73
Management of CKD in Diabetes
Case 3
Case 3
Systemic Lupus Erythematosus (SLE)
SLE ndash Lupus Nephritis
Case 5
Case 5
Slide Number 81
Slide Number 82
Case study
Slide Number 84
CXR ndash Hilar Lymphadenopathy
Whats needed next
Slide Number 87
newly dx ckd
Slide Number 89
Bibliography
bibliography
bibliography
bibliography
bibliography
BIBLIOGRAPHY
bull Matovinović M S (2009) Pathophysiology and classification of kidney disease Retrieved from The Journal of the International Federation of Clinical Chemistry and Laboratory Medicine httpwwwifccorgifccfilesdocs20010902pdf
bull Moe S Drueke T Lameire N amp Eknoyan G (2007 Jan) Chronic kidney disease-mineral-bone disorder a new paradigmdoi101053jackd200610005
bull Murtagh F E Marsh J E Donohoe P Ekbal N J Sheerin N S amp Harris F E (2007 July) Dialysis or not A comparative survival study of patients over 75 years with chronic kidney disease stage 5 Retrieved from Nephrology Dialysis and Transplant 22(7) httpswwwncbinlmnihgovpubmed17412702
bull National Kidney Foundation (2002) KDOQI clinical practice guidelines for chronic kidney disease evaluation classification andstratification American Journal of Kidney Disease S1-S266
bull National Kidney Foundation (2014 November 5) Fact Sheets Retrieved from httpwwwkidneyorgnewsnewsroomfactsheetsFastFacts
bull Pal S (2012 June 2) Trends in chronic kidney disease Retrieved from US Pharmacist (37)6 httpswwwuspharmacistcomarticletrends-in-chronic-kidney-disease
bull Qunibi W amp Henrich W L (2017 Jan 19) Overview of chronic kidney disease-mineral and bone disorder (J Berns amp A M Sheridan Eds) Retrieved from UpToDate httpswww-uptodate-comoverview-of-chronic-kidney-disease-mineral-and-bone-disorder-ckd-mbd
bull Rosenberg M (2016 Feb 24) Overview of the management of chronic kidney disease in adults (G C Curhan amp A M Sheridan Eds) Retrieved from UpToDate UpToDate httpswww-uptodate-comproxywichitaeducontentsoverview-of-the-management-of-chronic-kidney-disease-in-adults
BIBLIOGRAPHY
bull Szczech L Stewart R C Hsu-Lin S DeLosky R J Astor B C Fox C H Vassalotti J A (2014) Primary care detection of chronic kidney disease in adults with type 2 diabetes The ADD-CKD Study (Awareness Detection and Drug Therapy in type 2 diabetes and chronic kidney disease PLOS doihttpsdoiorg101371journalpone0110535
bull USRDS (2016) Annual data report 2016 Epidemiology of kidney disease in the United States Retrieved from United States Renal Data System httpswwwusrdsorgadraspx
bull Vasudev B amp Vasudev M (2012) A model curriculum for residents rotating in nephrology MedEDPORTAL doihttpdoiorg1015766mep_2374-82658288
bull Wei L MacDonald T M Jennings C Sheng X amp Flynn R W (2013) Estimated GFR reporting is associated with decreased nonsteroidal anti-inflammatory drug prescribing and increased renal function Kidney International (84)1 174-178
chronic kidney disease in primary care
CKD as a Public Health Issue
Slide Number 3
Costs of CKD in 2013 dollarsUSRDS report
Steps to CKD Patient Care
Renal anatomy and physiology
Definition of Chronic Kidney Disease
CKD Risk Factors
Gaps in CKD Diagnosis
Slide Number 10
Steps to CKD Patient Care
creatinine
Glomerular filtration rate
Slide Number 14
Slide Number 15
Use These Equations Cautiously if at all in hellip
lab albumin creatinine ratio
The New CKD Categories
Steps to CKD Patient Care
Slide Number 20
Kidney Involvement in Systemic Diseases
Slide Number 22
Slide Number 23
DysmorphicRenal Hematuria
Slide Number 25
If you have albuminuria or hematuria-order the following labs
Prevalence of Abnormalities of Mineral Metabolism PTH in CKD
Managing CKD-MBD complications
CKD-MBD Testing
Anemia Becomes More Common as Kidney Function Declines
Detect and Manage CKD Complications
Complications-metabolic acidosis
Complications-vascular calcification
Hyperkalemia management
Hyperuricemia levels amp CKD
CKD monitoring levels 345
Slide Number 59
When to Refer to a Nephrologist
When to Refer
Steps to CKD Patient Care
Kidney transplantation
Starting Dialysis in the ElderlyhellipOr Not
Ckd management
Case 1
Slide Number 67
Lab results
Slide Number 69
Hypertensive nephropathy with proteinuria
Slide Number 71
Case 2
Slide Number 73
Management of CKD in Diabetes
Case 3
Case 3
Systemic Lupus Erythematosus (SLE)
SLE ndash Lupus Nephritis
Case 5
Case 5
Slide Number 81
Slide Number 82
Case study
Slide Number 84
CXR ndash Hilar Lymphadenopathy
Whats needed next
Slide Number 87
newly dx ckd
Slide Number 89
Bibliography
bibliography
bibliography
bibliography
bibliography
BIBLIOGRAPHY
bull Szczech L Stewart R C Hsu-Lin S DeLosky R J Astor B C Fox C H Vassalotti J A (2014) Primary care detection of chronic kidney disease in adults with type 2 diabetes The ADD-CKD Study (Awareness Detection and Drug Therapy in type 2 diabetes and chronic kidney disease PLOS doihttpsdoiorg101371journalpone0110535
bull USRDS (2016) Annual data report 2016 Epidemiology of kidney disease in the United States Retrieved from United States Renal Data System httpswwwusrdsorgadraspx
bull Vasudev B amp Vasudev M (2012) A model curriculum for residents rotating in nephrology MedEDPORTAL doihttpdoiorg1015766mep_2374-82658288
bull Wei L MacDonald T M Jennings C Sheng X amp Flynn R W (2013) Estimated GFR reporting is associated with decreased nonsteroidal anti-inflammatory drug prescribing and increased renal function Kidney International (84)1 174-178
chronic kidney disease in primary care
CKD as a Public Health Issue
Slide Number 3
Costs of CKD in 2013 dollarsUSRDS report
Steps to CKD Patient Care
Renal anatomy and physiology
Definition of Chronic Kidney Disease
CKD Risk Factors
Gaps in CKD Diagnosis
Slide Number 10
Steps to CKD Patient Care
creatinine
Glomerular filtration rate
Slide Number 14
Slide Number 15
Use These Equations Cautiously if at all in hellip
lab albumin creatinine ratio
The New CKD Categories
Steps to CKD Patient Care
Slide Number 20
Kidney Involvement in Systemic Diseases
Slide Number 22
Slide Number 23
DysmorphicRenal Hematuria
Slide Number 25
If you have albuminuria or hematuria-order the following labs
![An Immunofixation TutorialVladutiu AO. 1995. Immunoselection vs immunofixation for light chain typing [Letter]. Clin Chem 41(6):947-948. Zent CS, Wilson CS, Tricot G. 1998. Oligoclonal](https://img.pdfslide.us/doc/110x75/5e5fbe94150aec635f375881/an-immunofixation-tutorial-vladutiu-ao-1995-immunoselection-vs-immunofixation.jpg)
