Transcript Why this CME on CKD

Why this CME on CKD ?
• CKD is a major global pandemic like DM
• DM and HT make CKD burden very high
• CKD predicts CVD – the major threat
• Testing and therapy are inadequately used
• Knowledge on CKD is at best sketchy
• Testing and early therapy are economical
• Most of the progression is preventable
www.drsarma.in
1
Do we care about CKD ?
1. Doctors do not realize that CKD is hidden in
their patients of DM, HT and in elderly people
2. Most doctors screen less than 10% of their
clinic patients for CKD in its early stages
3. Patients are referred very late to nephrologists
especially after the CKD is irreversible
4. Only < 1/4 of people with identified CKD get
an ACE Inhibitor – all are true - all over the globe
www.drsarma.in
2
What is the role of GPs ?
1. Recognize who is at risk of CKD
2. Consider all DM and HT as potential CKD pt.
3. Evaluate all at risk cases; Rx. hypertension
4. Understand eGFR, Albuminuria, MAU
5. Stage the CKD and manage appropriately
6. Must start patients on ACEi or ARB early
www.drsarma.in
3
Some useful Definitions
1. Azotemia - Elevated blood urea nitrogen - Biochemical
(BUN >28 mg/dl) and creatinine (Cr >1.5mg/dl)2. Uremia is Azotemia + symptoms or signs of renal failure
3. End Stage Renal Disease (ESRD) - Uremia requiring
transplantation or dialysis (Renal replacement therapy)
4. Chronic Renal Failure (CRF) - Irreversible kidney
dysfunction with azotemia >3 months – now not used
5. Creatinine Clearance (CCr) - The rate of filtration of
creatinine by the kidney (a marker of GFR)
6. Glomerular Filtration Rate (GFR) - The total rate of
filtration of fluid from blood by the kidney
www.drsarma.in
4
Clinical Features – CKD 3-5
• Unintentional weight loss
• Nausea, vomiting General ill feeling
• Fatigue; Headache; Frequent hiccups
• Generalized itching (pruritus)
• Increased or decreased urine output
• Need to urinate at night, polyuria
• Easy bruising or bleeding
www.drsarma.in
5
Clinical Features – CKD 3-5
• Blood in the vomit or in stools
• Decreased alertness; Muscle cramps
• Seizures; Agitation; Hypertension
• Peripheral sensory neuropathy
• Breath fetor; Loss of appetite;
• Uremic frost on the skin
• Uremic pericarditis, CHF
www.drsarma.in
6
Who are at Risk for CKD ?
•
•
•
•
•
•
•
•
Diabetes, Hypertension
Age , Family H/o Kidney Disease
Systemic Infections
Recurrent UTI
Urinary Stone Disease
Loss of Renal mass
Neoplasia of any part
Nephrotoxic Drugs (NSAIDs)
www.drsarma.in
7
Etiology of CKD
1. Diabetes - most common cause ESRD (risk 13 x )
2. Over 30% cases ESRD are primarily due to diabetes
3. CKD associated HTN causes @ 23% ESRD cases
4. Glomerulonephritis accounts for ~10% cases
5. Polycystic Kidney Disease - about 5% of cases
6. Rapidly progressive glomerulonephritis (vasculitis) about 2% of cases; Drug induced Tubulo-interstitial
7. Renal Vascular Disease - renal artery stenosis
(ARAS), atherosclerotic vs. fibromuscular
www.drsarma.in
8
Definition of CKD
1. Either GFR < 60 ml/min/1.73m2 for  3 mon or
2. Kidney damage for  3 mon as manifested by
a. Persistent microalbuminuria /
macroproteinuria
b. Biochemical abnormalities in RFT
c. Persistent non-urological hematuria
d. Structural renal abnormalities by USG
e. Biopsy proven Glomerulonephritis
(Any one of the above evidences)
www.drsarma.in
9
CKD Clinical Stages
Stage Description
GFR
(ml/min/1.73 m2)
1
Kidney damage with normal or ↑ GFR
 90
2
Kidney damage with mild  GFR
60-89
3
Kidney damage with moderate  GFR
30-59
4
Severe  GFR
15-29
5
Kidney Failure (ESRD)
< 15 (or dialysis)
www.drsarma.in
10
How to investigate CKD
• All subjects
1.
2.
3.
4.
Measurement of blood pressure
eGFR calculation using serum creatinine
Albumin Creatinine Ratio (ACR)
Urine sediment dipstick for RBC, WBC
• Selected subjects
1. USG, Serum electrolytes, Ca, Ph, PTH
2. Urine osmolality, Na, Specific gravity
www.drsarma.in
11
What Tests We need for CKD ?
1. Serum creatinine test, age, gender to note
2. Estimate GFR from serum creatinine (MDRD)
3. Standard dipstick for urine protein – if negative
4. Spot urine albumin to creatinine ratio (ACR)
5. 24 hour urine collections are NOT needed.
6. Diabetics should be tested at least once a yr.
7. Others at risk to be tested once in 2 years
www.drsarma.in
12
Why eGFR? Why not Creatinine?
Age
Gender
Race
SCr
(mg/dL)
20
M
B
1.3
91
1
20
M
W
1.3
75
2
55
M
W
1.3
61
2
20
F
W
1.3
56
3
55
F
B
1.3
55
3
85
F
W
1.3
41
3
www.drsarma.in
(ml/min/1.73 m2)
CKD
Stage
eGFR
13
MDRD Equation
eGFR calculation
eGFR (ml/min/1.73m2) =
175 x (Serum Creatinine in mg%) – 1.154 X
(Age in years) – 0.203 X
(0.742 if women) X
(1.210 if Black ethnicity)
This formula is internationally validated
www.drsarma.in
14
Interpretation of Albuminuria
Spot Urine only
(No 24 hr urine please)
Albumin : Creatinine Ratio (ACR)
(Urine albumin in mg per liter ÷
Urine creatinine in mg/dl) x 100
No Albuminuria
Less than 30 mg/g
Micro Albuminuria
30 to 300 mg/g
Macro Albuminuria
More than 300 mg/g
Nephrotic Proteinuria
More than 3000 mg/g
www.drsarma.in
15
Imp. of Albuminuria in CKD
1. Marker of CKD
• Spot ACR > 30 mg/g for more
than 3 months (MAU)
2. Clue to Dx. CKD
• Spot ACR > 500 mg/g indicates
DKD, Glomer, Transplant GP
• Higher proteinuria - severe CKD
3. Prognostic Index
and higher CV risk indicator
4. Modified by Rx.
• B.P control, use of ACEi / ARBs
slow CKD predict improvement
5. Surrogate Goal
• Validated as the marker for CKD
and is the goal of therapy
www.drsarma.in
16
Metabolic Effects of CKD 3-5
1.
2.
3.
4.
5.
6.
7.
8.
Hyperkalemia
Mixed Metabolic acidosis
Fluid loss/ Fluid over load (Stage 5)
Hyponatremia or Hypernatrimia
Normocytic normochromic anaemia
Increased Ph, ↓ Calcium, ↓ Vitamin D
Secondary ↑ in PTH
Renal Osteodystophy
www.drsarma.in
17
CKD – Management Goals
1. Blood pressure < 125/75
– HT is both a cause and consequence
2. Glycemic control – Hb A1c < 6.5
3. Hemoglobin level > 11 g%
4. Calcium x Phosphorous product < 50
Normal values :
GFR 120 to 150 ml/min/1.73m2
Ca 9 to10.5mg%, Ph 3 to 4.5mg%, Ca x Ph < 50
iPTH 150 to 300 pg/ml
www.drsarma.in
18
Stage-wise management of CKD
Stage 0
Test for CKD, Management of Risk Factors
Stage 1
Manage co-morbidity, Rx. of CVD and RF
Stage 2
Slow rate of loss of Kidney function - ACEi
Stage 3
Prevent Anemia, Bone effects, Ca x Ph
Stage 4
Preparation for RRT; refer to nephrology
Stage 5
RRT – PD, HD or RT – Donor / Cadavre
www.drsarma.in
19
Recommendations for BP and
RAS Management in CKD
Patient
Group
+ Diabetes
Goal BP
(mm Hg)
First Line
Adjunctive Drugs
<125/75 ACE-I or ARB Diuretics then CCB or BB
 Diabetes
<125/75 ACE-I or ARB Diuretics then CCB or BB
+ Proteinuria
 Diabetes
<130/80
 Proteinuria
www.drsarma.in
No specific preference:
Diuretics then ACE-I, ARB, CCB, or BB
© 2005 The Johns Hopkins University School of Medicine.
20
Diabetic Nephropathy
Management Summary
BLOOD PRESSURE TARGET 125 / 75
ACEi + ARB
MRA
GLYCEMIA CONTROL TARGET Hb A1c < 6.5
TZDs, ? Metformin,
Insulin (early)
LDL CHOLESTEROL < 100 (70) mg%
Early Statin Rx
Ezetemebe, Others
ANAEMIA Rx. TARGET HB > 11 g
Erythropoetin
Iron supplementation
ENDOTHELIAL DYSFUNCTION
Aspirin 150 mg o.d
www.drsarma.in
Smoking cessation
21
Anemia in CKD
• Decreased production
– Low EPO (RF)
– Nutritional
• (Iron, B12, Folate)
– inflammation
– Infection, Ca
• Blood Loss
• Serum Erythropoietin
levels not indicated
www.drsarma.in
• Reticulocyte count
• Red Blood Cell indices:
MCV, RDW
• Iron Parameters
– TIBC
– Serum Ferritin
• Vitamins:
– Folate\B12 levels
• Stools for occult blood
22
Phosphate Control
• Dietary restriction of phosphorous
• Phosphate binders to ↓↓ absorption
– CaCo3 ( BoneStat)
– Ca acetate (PhosLo)
– Sevelamer (RenaGel)
– Al hydroxide, Al carbonate
– PhosRenal (Lanthanum Carbonate)
• Removal of Phospherous by dialysis is poor
www.drsarma.in
23
Special Treatment in CKD
Calcium acetate (PhosLo)
1334 mg PO with each meal
Calcium Crabonate
Sandocal, Bonestat, Oyestercal, Cipcal
1-2 g bid with each main meal
Calcitriol (Vitamin D), Paricalcitriol
0.25 mcg PO once a day
Doxercalciferol (Vitamin D analog)
10 mcg PO x 3 times a week
www.drsarma.in
24
Special Treatment in CKD
 Sevelamer (RenaGel) –
800 to 1600 mg PO with meal
 Calcimimetics – Cinacalcet - ↓ PTH
Sensipar orally with meal
30 mg PO once day – up to 120 mg
PTH target of 150 to 300 pg/ml
 Eplerenone (Selective MRA)
Eplaristat
 Lanthenum Carbonate (FosRenal)
250 to 500 mg tid to be chewed
www.drsarma.in
25
Important Guidelines
Interventions to slow
progression of CKD
To be avoided to prevent
acute reduction in GFR
1. Glycemic control in DM 1. Volume depletion
2. BP control ACEI / ARB
2. Radiographic contrast
3. Protein restriction
3. Antibiotics / NSAIDS
4. Lipid lowering therapy
4. Cyclosporine / tacrolimus
5. Weight reduction
5. ACEI / ARB if Cr > 3.5mg
6. Anemia Rx, Smoking
6. Obstructive uropathy
www.drsarma.in
26
Preparation for RRT
•
•
•
•
Choice of Renal Replacement
Timely Access Surgery
Timely Dialysis initiation
When GFR < 25ml/min
– Renal transplant is the first choice
– Workup living donors
– If no donors available
– List patient on cadavre transplant list
– Place A-V fistula if HD preferred
www.drsarma.in
27
Indications for Hemodialysis
Absolute indications (Chronic)
• GFR < 15 ml – Stage 5
• Creatinine > 8, BUN >100
• K > 7.0 meq persistently
• Refractory CHF, Diuretic F
• Accelerated Hypertension
• Uremic pericarditis
• Uremic encephalopathy
• Uremic Bleeding, Vomiting
www.drsarma.in
•
•
•
•
•
•
•
Acute indications
Poisoning - dialysable
Drug over dosage
ARF > 48 hours
GFR < 30 ml
Metabolic acidosis
Hyperkalemia
Hyperphosphatemia
28
Nephrotoxic Drugs
• Which drug is (not) nephrotoxic?
– Antibiotics
• Aminiglycosides, Indinavir, Amphotericin
• Penicillin / -lactums, Tetracyclines
• Fluoroquinolones, Sulphas, Ketoconozole
– NSAIDS/ COX2 inhibitors, Indomethacin
– Cancer: MTX, Cisplatin, Acyclovir, Pentamidine
– Heavy metals: Hg, Pb, Ar, Bi, Lithium
– IV Contrast dyes; ACE inhibitors / ARBS
www.drsarma.in
29
Take Home Messages
• CKD is a silent killer – we need to uncover it
• CKD progression is preventable – Stage it and Rx.
• DM most common cause of ESRD all over globe
• CKD - more likely CV death than progress to ESRD
• Multi-risk factor intervention is critical, Hb A1c goal
• Lowering blood pressure with RAAS blockade
• Combinations of ACEi + ARB ± MRA
• Prevent cardiovascular morbidity and mortality
www.drsarma.in
30