CKD and CDM CKD and CDM FYIFYI

Dr. Maggie WattDr. Maggie Watt

Mr. H. E.Mr. H. E. 72 year old retired truck driver72 year old retired truck driver New patient in April 2002New patient in April 2002 PMHxPMHx

MI 1983MI 1983 Pituitary Tumour 1983 resected and 6/12 XRTPituitary Tumour 1983 resected and 6/12 XRT Panhypopituitarism (on Cortisone, Synthroid Panhypopituitarism (on Cortisone, Synthroid

& Testosterone replacement)& Testosterone replacement) Renal insufficiency following TUPR Renal insufficiency following TUPR

bilateral ureteral obstruction Oct 2001bilateral ureteral obstruction Oct 2001 Thickened bladder wall and outlet obstructionThickened bladder wall and outlet obstruction Creat 150 (no GFR reported yet)Creat 150 (no GFR reported yet)

Mr. H.E. (cont’d)Mr. H.E. (cont’d)

55 pack year smoker – multiple 55 pack year smoker – multiple attempts to quitattempts to quit

Past alcoholic (quit 1983)Past alcoholic (quit 1983) HTNHTN HypercholesterolemiaHypercholesterolemia Type 2 DM (dx May 2004)Type 2 DM (dx May 2004) Obesity (BMI 39.2)Obesity (BMI 39.2)

Mr. H.E. cont’dMr. H.E. cont’d

May 2003 – BP 180/110May 2003 – BP 180/110 Start Altace 2.5 mg daily, titrated to 10 mg Start Altace 2.5 mg daily, titrated to 10 mg

over 2/12over 2/12 Cough on ACEI – change to CozaarCough on ACEI – change to Cozaar

Dec 2003 – BP 150/50Dec 2003 – BP 150/50 Add HCTZAdd HCTZ

April 2004 April 2004 Creat 162, GFR 39 (Stable)Creat 162, GFR 39 (Stable) Enroll in PROMIS (Kidney Care Initiative)Enroll in PROMIS (Kidney Care Initiative)

Mr. H.E. cont’dMr. H.E. cont’d

May 2004…my chart notes changeMay 2004…my chart notes change Review bloodwork (FBS 12.7 = Type 2 DM)Review bloodwork (FBS 12.7 = Type 2 DM) ““Stage 3 CKD” (GFR 41)Stage 3 CKD” (GFR 41) Hyper PTH (secondary)Hyper PTH (secondary) Urine ACR elevated (2.67) (normal < 2 Urine ACR elevated (2.67) (normal < 2

males)males) Plan – Renal U/S, Refer NephroPlan – Renal U/S, Refer Nephro New goal for Lipids in view of DM 2 and New goal for Lipids in view of DM 2 and

CKDCKD LDL < 2.5 and TC/HDL <4LDL < 2.5 and TC/HDL <4

Further InvestigationsFurther Investigations

Renal ultrasound June 2004Renal ultrasound June 2004 Bilateral mild symmetric cortical Bilateral mild symmetric cortical

thinningthinning Left kidney 11.4 cm, right kidney 9.2 Left kidney 11.4 cm, right kidney 9.2

cmcm No hydronephrosisNo hydronephrosis Bladder normalBladder normal

And then he sees the And then he sees the nephrologistnephrologist

Dr. Stigant – October 2004Dr. Stigant – October 2004 3 page consult3 page consult CKD moderate in severityCKD moderate in severity Small vessel renovascular diseaseSmall vessel renovascular disease Possibly component of macrovascular Possibly component of macrovascular

dz (asymmetric kidney size on u/s)dz (asymmetric kidney size on u/s) Twice yearly ACR and renal functionTwice yearly ACR and renal function Follow up 1 yearFollow up 1 year

Dr. Stigant November 2005Dr. Stigant November 2005 Stable moderate impairment in kidney functionStable moderate impairment in kidney function Query right renal artery stenosisQuery right renal artery stenosis

Nuclear renal scan with lasix (Dec 2005)Nuclear renal scan with lasix (Dec 2005) ““asymmetry of kidney function raises possibility of right asymmetry of kidney function raises possibility of right

renal artery stenosis”renal artery stenosis” Feb 2006 – acute decline in renal fxn GFR 16Feb 2006 – acute decline in renal fxn GFR 16

Book MRA, possible dialysis, D/C Book MRA, possible dialysis, D/C antihypertensives, ASAantihypertensives, ASA

Renal MRA - March 2006Renal MRA - March 2006 Severe stenosis at origin of right renal arterySevere stenosis at origin of right renal artery

Nov. 2006 - Angioplasty and Stent placement in Nov. 2006 - Angioplasty and Stent placement in Right Renal ArteryRight Renal Artery

70% stenosis70% stenosis Renal function unchanged but felt almost instantly betterRenal function unchanged but felt almost instantly better

Current Status Mr. H.E.Current Status Mr. H.E.

Q 3/12 Diabetes Check, CKD CheckQ 3/12 Diabetes Check, CKD Check HTN, Sugars, Renal Fxn, Lipids, Self Care, etc.HTN, Sugars, Renal Fxn, Lipids, Self Care, etc. Motivated re: self careMotivated re: self care

Recent weight lossRecent weight loss Stable renal functionStable renal function Upcoming knee replacement June 2008Upcoming knee replacement June 2008 Awaiting resection of parathyroid Awaiting resection of parathyroid

adenoma (has primary and secondary adenoma (has primary and secondary PTH)PTH)

BC CKD GUIDELINESBC CKD GUIDELINES

Identify high risk populations:Identify high risk populations: Family history of kidney diseaseFamily history of kidney disease vascular diseasevascular disease DMDM HTNHTN high risk ethnicity (First Nations, S. high risk ethnicity (First Nations, S.

Asian, Hispanic, African American, Asian, Hispanic, African American, Pacific Islanders)Pacific Islanders)

(age (age >60)>60)

BC CKD GuidelinesBC CKD Guidelines Screen Screen high risk high risk populations (q 1-2 years)populations (q 1-2 years)

Serum creatinine and eGFRSerum creatinine and eGFR Urine ACRUrine ACR Urinalysis ( to detect protein, WBC’s, RBC’s)Urinalysis ( to detect protein, WBC’s, RBC’s)

Evaluate patients with Evaluate patients with sustained impairmentssustained impairments Determine Determine cause of CKD cause of CKD

Renal ultrasoundRenal ultrasound Identify care objectivesIdentify care objectives

Involve patients in Involve patients in self-managementself-management

Diagosis of CKDDiagosis of CKD

Sustained GFR < 60 Sustained GFR < 60 mL/minmL/minNote: eGFR not accurate > Note: eGFR not accurate > 6060

ProteinuriaProteinuriaMicrovascular +/- glomerular Microvascular +/- glomerular diseasedisease

Symptoms of CKDSymptoms of CKD

Causes of CKDCauses of CKD Diabetes (Type 1 and Type 2)*Diabetes (Type 1 and Type 2)* Hypertension*Hypertension* Other vascular diseasesOther vascular diseases

Large vessel disease, microangiopathyLarge vessel disease, microangiopathy Glomerular diseases:Glomerular diseases:

Autoimmune, systemic infection, drugs, Autoimmune, systemic infection, drugs, neoplasianeoplasia

Tubulointerstitial DisiasesTubulointerstitial Disiases UTI, stones, obstruction, drug toxicityUTI, stones, obstruction, drug toxicity

Polycystic Kidney DiseasePolycystic Kidney Disease(*account for 2/3 of CKD and ESRD)(*account for 2/3 of CKD and ESRD)

PROTEINURIA - PROTEINURIA - DefinitionsDefinitions

MICROALBUMINURIAMICROALBUMINURIA 24 hour urinary albumin excretion 30 - 300 mg24 hour urinary albumin excretion 30 - 300 mg Urine ACRUrine ACR

< 2.0 mg/mmol (M)< 2.0 mg/mmol (M) < 2.8 mg/mmol (F) < 2.8 mg/mmol (F) Sustained (ie. 2/3 samples)Sustained (ie. 2/3 samples)

PROTEINURIA (‘overt’)PROTEINURIA (‘overt’) 24 hour urine protein excretion > 150 mg/day24 hour urine protein excretion > 150 mg/day Transient, orthostatic, or persistentTransient, orthostatic, or persistent

NEPHROTIC RANGE PROTEINURIANEPHROTIC RANGE PROTEINURIA > 3 grams/day> 3 grams/day Typically associated with glomerular diseaseTypically associated with glomerular disease

WHEN TO REFERWHEN TO REFER

Sustained decline in GFR < 30mL/minSustained decline in GFR < 30mL/min Acute renal failureAcute renal failure Subacute decline in kidney functionSubacute decline in kidney function

>10 mL/min annually>10 mL/min annually Sustained proteinuria > 1gram/24 hrsSustained proteinuria > 1gram/24 hrs Active urine sedimentActive urine sediment

Cellular casts, sustained hematuria &/or Cellular casts, sustained hematuria &/or proteinuriaproteinuria

DEFINITIONS / DEFINITIONS / CLARIFICATIONCLARIFICATION

Certain kidney diseases often require Certain kidney diseases often require specificspecific management: management: GlomerulonephritisGlomerulonephritis Obstructive uropathyObstructive uropathy Acute interstitial nephritisAcute interstitial nephritis Renal artery stenosisRenal artery stenosis

Non-disease specificNon-disease specific therapies aimed at therapies aimed at slowing progressive nephropathy, slowing progressive nephropathy, regardless of:regardless of: Disease etiologyDisease etiology Stage of CKDStage of CKD

A BRIEF REVIEW – CKD A BRIEF REVIEW – CKD TreatmentTreatment

Consider reversible factorsConsider reversible factors Avoid nephrotoxins Avoid nephrotoxins

NSAIDs, contrast, aminoglycosidesNSAIDs, contrast, aminoglycosides Slow CKD progression:Slow CKD progression:

BP <130/80 (or 125/75 if proteinuria >1 gram/day)BP <130/80 (or 125/75 if proteinuria >1 gram/day) Consider ACEi or ARB therapyConsider ACEi or ARB therapy Control BG in diabetics (HgA1c <7%)Control BG in diabetics (HgA1c <7%) +/- dyslipidemia therapy+/- dyslipidemia therapy +/- dietary protein restriction+/- dietary protein restriction

Follow CHEP, CDA, CCS guidelines for secondary Follow CHEP, CDA, CCS guidelines for secondary cardiovascular preventioncardiovascular prevention

END-STAGE KIDNEY DISEASE END-STAGE KIDNEY DISEASE CAN BE PREVENTED (OR CAN BE PREVENTED (OR

SLOWED)SLOWED)%

of

norm

al f

unct

ion

Time

Diagnosis and Treatment

100

Time on Dialysis

GFR DECLINES WITH GFR DECLINES WITH AGEAGE

Normal decline 1 % per year

IMPLICATIONSIMPLICATIONS

Patients need information on CVD / mortality Patients need information on CVD / mortality risk not just progressive nephropathyrisk not just progressive nephropathy

Patients with progressive disease need info Patients with progressive disease need info on preparation for RRTon preparation for RRT

Older patients may benefit less than younger Older patients may benefit less than younger from intensive therapeutic effortsfrom intensive therapeutic efforts

Male patients may require more aggressive Male patients may require more aggressive evaluation, treatment, follow-up, and earlier evaluation, treatment, follow-up, and earlier referralreferral

More predictors of progressive CKD requiredMore predictors of progressive CKD required

PROTEINURIA - PROTEINURIA - SUMMARYSUMMARY

Proteinuria is significant whenProteinuria is significant when Sustained (>3mos)Sustained (>3mos) High-gradeHigh-grade

Always warrants nephrology referralAlways warrants nephrology referral

TreatmentTreatment Lower BP (ACEi or ARB first line)!Lower BP (ACEi or ARB first line)! Treat diabetes to targetTreat diabetes to target Attend to other CV risk factorsAttend to other CV risk factors

ANEMIA - SUMMARYANEMIA - SUMMARY Increasing prevalence with reduced kidney Increasing prevalence with reduced kidney

functionfunction Transferrin Saturation better gauge of iron Transferrin Saturation better gauge of iron

stores than Ferritin at low GFRstores than Ferritin at low GFR Prescribe erythropoietin therapy Prescribe erythropoietin therapy

(Nephrology)(Nephrology) After other causes of anemia ruled outAfter other causes of anemia ruled out After iron stores repleteAfter iron stores replete

Monitor response to therapy monthlyMonitor response to therapy monthly Therapy usually well tolerated but watch for HTN Therapy usually well tolerated but watch for HTN

with rapid increases in Hgbwith rapid increases in Hgb Maintain target hemoglobin 110-130 – Maintain target hemoglobin 110-130 –

increased mortality outside that rangeincreased mortality outside that range

Bone Mineral Bone Mineral MetabolismMetabolism

Objectives for Stage 3 Objectives for Stage 3 CKDCKD Disease State :Disease State :

HyperphosphatemiaHyperphosphatemiaHypocalcemiaHypocalcemiaDecreased Calcitriol (activated Decreased Calcitriol (activated

Vit D)Vit D)

all increase PTHall increase PTH

Treatment sequence Treatment sequence (Not a medical emergency)(Not a medical emergency)

1. Dietary Phosphate restriction 1. Dietary Phosphate restriction (target normal PO4 level)(target normal PO4 level)

2. Calcium-based binders with meals 2. Calcium-based binders with meals (target normal Ca and P04 levels)(target normal Ca and P04 levels)

Start TUMS 1 tab with each meal (decrease Start TUMS 1 tab with each meal (decrease P04 and increase Ca2+)P04 and increase Ca2+)

3. Alpha Calcidiol (if PTH > 7.7 pmol / L)3. Alpha Calcidiol (if PTH > 7.7 pmol / L) One-alpha 0.25 mg dailyOne-alpha 0.25 mg daily

Monitor labs q 6 mos in treatment Monitor labs q 6 mos in treatment phasephase

Hyper PTH in CKDHyper PTH in CKD

Need to target progressively higher Need to target progressively higher PTH to maintain normal bone PTH to maintain normal bone turnover as CKD progressesturnover as CKD progresses

Caused by skeletal resistance to PTHCaused by skeletal resistance to PTH

* opinion based levels* opinion based levels

CKD Stage GFR Target PTH *3 30-60 3.8-7.74 15-29 7.7 - 125 < 15 (dialysis) 16.5 - 33

SUMMARY – MINERAL SUMMARY – MINERAL METABOLISMMETABOLISM

Measure Ca / PO4 / PTH (and Measure Ca / PO4 / PTH (and albumin) at least yearlyalbumin) at least yearly

Restrict dietary PO4 intakeRestrict dietary PO4 intake When hyperphosphatemia occurs: When hyperphosphatemia occurs:

Reinforce dietary PO4 restrictionReinforce dietary PO4 restriction start PO4 binders (typically Ca-based)start PO4 binders (typically Ca-based)

Maintain normal serum Ca levelsMaintain normal serum Ca levels Rx Vitamin D if hypocalcemic or if Rx Vitamin D if hypocalcemic or if

PTH above targetPTH above target

How has Toolkit/CDM been How has Toolkit/CDM been usefuluseful

Learn and follow guidelinesLearn and follow guidelines Planned follow-up Planned follow-up

need to develop recall systemneed to develop recall system CDM visits are MY agendaCDM visits are MY agenda Office visits more organized / less Office visits more organized / less

harriedharried ““Shared care” with nephrologistShared care” with nephrologist ease of billingease of billing