Chronic Kidney Disease - managing complications of CKD

Arasu Gopinath, MD Nephrology Associates of Utah

e & oe

Declaration of Independence

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I am not indebted to anyone except…. My parents My family My teachers My friends My colleagues My bank My credit union ………….

Prevalence of CKD by age & risk factor among NHANES participants, 1998-2012

Vol 1, CKD, Ch 1 3

CVD in patients with or without CKD, 2012

USRDS database

Why does it matter?

CKD classification and prognosis

CKD complications 1. Drug toxicity

1. Errors in drug dosing 2. Drug – drug interactions 3. Drug toxicity

2. Metabolic / Endocrine 1. Anemia 2. Acidosis 3. Malnutrition 4. Hyperkalemia 5. Bone and mineral disorders

3. Cardiovascular Disease 1. Hypertension 2. Volume overload

4. Death

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Hyperkalemia in CKD Most potassium is intracellular.

intracellular conc. 100-120 mmol/L extracellular conc. 4 mmol/L

Common medications that lead to hyperkalemia ACEI and ARB Angiotensin Receptor Antagonist Digoxin K sparing agents (Amiloride/ Triamterene, Trimethoprim,

Pentamidine) Beta blocker

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Hyperkalemia Higher dietary potassium intake is not a cause of

hyperkalemia unless: Very large amounts over short time with stage III CKD Impairment of urinary potassium excretion EGFR <45 ML per

minute

Transient hyperkalemia can be caused by Annette release of potassium from cells

Chronic hyperkalemia is maintained by impairment of potassium excretion Chronic kidney disease Decreased aldosterone or effect of aldosterone Decreased sodium and or water delivery distally

Lazich L et al Sem in Neph: 2014;33:333-339

Predictors of hyperkalemia (> 5.5) eGFR < 45 ml/min/1.73 sq.m

Baseline K > 4.5 on diuretics

BMI < 26 kh/sq.m (adipocytes produce

some aldosterone)

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Lazich L et al. Semin Nephrol 2014;33:333-339

Chronic Hyperkalemia

Management Diuretics Diet (2 grams of potassium per day) Potassium binding resins ○ Sodium polystyrene sulfonate (unclear if it works) ○ Patiromer (exchanges K for Ca) ○ ZS9, ZS10

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Patiromer

FDA approved in July 2015

chronic hyperkalemia exchanges K for Ca 8.4 g or 16.4 g dose powder, dissolve in 90

ml of water constipation (14.5%)

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Mineral Bone disorder

Mineral Bone disorder

Mineral Bone disorder

Why does it matter?

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Mineral Bone disorder

Vit D levels decline and PTH levels increase with decreasing GFR

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Check serum Ca, Phos, PTHi and Alkaline Phosphatase at least once when eGFR < 60 ml/min/1.73 sq.m

Mineral Bone disorder

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Mineral Bone disorder

T- turnover M-Mineralization V- Volume

OM –Osteomalacia AD - Adynamic bone disease OF - Osteitis fibrosa MUO - Mixed uremic dystrophy

• Limiting dietary phosphorus • Avoid high phosphate foods

especially if low quality protein • Limiting dietary phosphorus may

worsen protein malnutrition

Mineral Bone disorder

• Phosphate binders with meals

• Calcium based binders (Tums, Phoslo)

• non-calcium binders if hypercalcemia occur

• Sevalamer and Lanthanum carbonate

• Sucroferric oxyhydroxide, Ferric citrate

• Controlling PTH levels • 1,25 dihydroxy Vitamin D (Calcitriol) • Vitamin D analogs

• Doxercalciferol • Paricalcitol

• Calcimimetic • Cinacalcet

• Avoid routine bone mineral density testing in eGFR < 45 ml/min/1.73 sq.m (does not predict risk accurately)

• Avoid bisphosphonates in eGFR < 30 ml/min/1.73 sq.m. • When PTHi is high, screen for hyperphosphatemia,

hypocalcemia or Vitamin D deficiency.

Mineral Bone disorder

IMC

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Delaying CKD progression

• Glycemic control • ~ A1c < 7

• BP control • goal BP < 130/80, if patient has UACR more than 30 mg/g • Goal BP < 140/90, if patient has UACR less than 30 mg/g

• Albuminuria reduction

• ACEI or ARB in all adults with UACR > 300 mg/g • ACEI or ARB in diabetics with UACR > 30 mg/g

SPRINT

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CKD exclusions

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SPRINT

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SPRINT

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SPRINT

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• Avoiding AKI • Avoid NSAIDs • Stop nephrotoxic agents prior to contrast • In GFR < 60 ml/min, avoid high osmolar

contrast, use lowest dose possible, hydrate with saline and repeat labs in 48-96 hours.

• Avoid phosphate containing bowel preparations

Delaying CKD progression

• Limiting protein intake ~ 0.8 g/kg/day in CKD 4-5 categories ~ not to exceed 1.3 g/kg/day in order to delay CKD

progression • Salt intake

~ < 2.0 gram of Sodium/day, i.e. < 5 g/day of salt

• Hyperuricemia ~ insufficient evidence

• Lifestyle changes

~ exercise 30 minutes 5 x week, goal BMI 20-25, quit smoking

Delaying CKD progression

NSAIDs in CKD

Impair glomerular autoregulation/ ATN Resistant hypertension and make anti hypertensives

less effective Acute interstitial nephritis Nephrotic syndrome (Minimal Change Disease and

Membranous Nephropathy) Acute papillary necrosis and hematuria Edema/ heart failure Distal RTA and nephrolithiasis Hyperkalemia Chronic use associated with CKD and its progression

dos and don’ts in CKD

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1. Medications - Use RAAS blockade when indicated - Avoid NSAIDs

2. Vein preservation - Preserve veins in non dominant arm - Avoid PICC and Mid lines, esp in stages G4-5

3. Contrast - Minimize contrast use and take appropriate precautions when contrast is to be administered in stages G3-5 - Avoid Gadolinum for MRI in stage G4-5

4. Anemia - Minimize blood draws (coordinate with others where possible)

5. Malnutrition - Do not limit protein intake if malnourished

Questions 1. A 60 year old obese white male, has type 2 diabetes,

hypertension and a creatinine of 2.0. He complains of arthralgia and has edema due to venous insufficiency. Usual meds are Glyburide-Metformin, Lisinopril and Atorvastatin.

Which of the following is likely to increase his risk for hyperkalemia? a. eGR < 45 b. obesity c. addition of Meloxicam for his arthralgia d. addition of Furosemide for his edema e. a + c f. b + d

Questions

2. Avoiding NSAIDs in CKD is part of the Choosing Wisely campaign. NSAIDs can lead to the following except: a. Hematuria b. Proteinuria c. Hypertension d. Edema e. Hypokalemia f. Hyponatremia

Questions

3. Which of the following is a pre-requisite for limiting proteinuria? a. Protein intake of approx 0.8 g/kg/day b. Serum Bicarbonate greater than 22 c. Salt intake of less than 5 grams a day d. Uric acid level of less than 6.5

Questions

4. Which of the following changes is not part of the mineral bone disorder of CKD

a. Hypocalcemia b. Hyperphosphatemia c. Low 25 hydroxy Vitamin D d. Elevated 1,25 di hydroxy Vitamin D e. Elevated PTH

Questions 5. All of the following are recommended

interventions to reduce contrast induced nephropathy when eGFR is < 30 ml/min except? a. Stop Metformin and nephrotoxins temporarily b. Avoid isosmolar contrast agents c. Hydrate with saline pre and post contrast d. Measure Creatinine/ eGFR 2-3 days post contrast

Answer key

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Question 1: e Question 2: e Question 3: c Question 4: d Question 5: b