Transcript Update in Nephrology

Update in Nephrology
2008
Jeff Kaufhold, MD FACP
Acute Dialysis Quality Initiative
• RIFLE Criteria Helps risk stratify patients
with renal failure.
• Increased mortality seen with increases in
creatinine of 0.3 to 0.5 mg/dl (70 %
increase for all pts, 300 % increase in
cardiac surgery pts
RIFLE criteria
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Risk low uop for 6 hours, creat up 1.5 to 2 times baseline
Injury creat up 2 to 3 times baseline, low uop for 12 hours
Failure Creat up > 3 times baseline or over 4, anuria
Loss of Function Dialysis requiring for > 4 weeks
ESRD Dialysis requiring for > 3 months
RIFLE estimate of Mortality
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Two studies
No renal failure
Risk
Injury
Failure
Loss of Function
ESRD
Uchino
4.4 %
15%
29%
53.9%
Crit Care Med 2006; 34:1913-7, Hoste CCM 2006; 10:R73
Hoste
5.5
8.8
11.4
26%
RIFLE criteria
• When markers of severity of illness are
looked at excluding renal data, no
difference in groups is seen.
New markers for ARF
• Creatinine is not very sensitive
• Cystatin C identifies ARF 1.5 days earlier
than creatinine
– KI 2004; 60:1115-1122
• KIM-1
• NGAL
Agents to Treat ARF
• Lasix still improves urine output, but may worsen
mortality
– Intensive care Med. 2005; 31: 79-85, JAMA 2002;288:2547-2553
• Fenoldapam may be helpful, especially in
cardiac surgery pts
– AmJKid Dis 2005;46:26-34
• Atrial Natriuretic Peptide may reduce need for
dialysis and mortality
– Crit Care Med 2004;32:1310-5.
• Dopamine still doesn’t work
– Ann Int Med 2005;142:510-24.
How do you differentiate ARF
from CRF.
• What physical exam finding tells you the pt
has Chronic Kidney Disease?
• What Would you see on renal Ultrasound
for a pt with CKD?
Lindsey’s Nails
CKD prevalence in world
Populations
• Country
– China
– India
– Indonesia
– Pakistan
– Phillipines
– Vietnam
Population
CKD est.
1.298.847.624
1.065.070.607
238.452.952
159.196.336
86.241.697
82.662.800
35.336.295
28.976.185
6.487.322
4.331.076
2.346.281
2.248.914
• Assumes 2.72 % incidence
CKD Stages
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Stage 1.
Stage 2.
Stage 3.
Stage 4.
Stage 5.
Stage 6.
Normal function with known dz
GFR 60-80
GFR 30-60
GFR 15-30.
GFR less than 15.
ESRD on dialysis.
US Population with CKD
Coresh, Selvin, Stevens. Prevalence of CKD in the US. JAMA.2007;298(17)2038.
Progression of CRF
80
70
60
50
40
GFR
30
20
10
0
PTH climbs PO4 rising K, Urate Up Anemia Sx
Preparation of the Patient
• Manage CRF
• Control BP
• Control glucose
– stop oral agents!
• Prevent Hyper PTH
– Vit D
– Calcium acetate
– Phosphate binder
• Diet Education
Urinary Albumin (mg/day)
Presence of MAU Indicates a
Potential Increased Risk for CV
Events
1,000
900
Macroalbuminuria
>300 mg/day
Increased CV Risk and Presence of
Renal and Vascular Dysfunction
800
700
600
500
400
300
200
100
MAU
30-299 mg/day
Increased CV Risk
and Vascular
Dysfunction
0
Normal
Cardiovascular Risk
Garg JP et al. Vasc Med. 2002;7:35-43. Eknoyan G et al. Am J Kidney Dis. 2003;42:617-622.
Preparation of the Patient
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Manage Fluids
Dialysis education
Access Placement
Prevent anemia
Prevent Malnutrition
Start ACE?
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metolazone
NKF program
AV fistula, PD cath
Epogen, Iron
This can get tricky
Stop ACE?
Transition to End Stage
Effect of Malnutrition
86
Wt
84
Measured Wt
= 85 Kg
82
Edema
Body mass
80
78
76
74
25
15
10
GFR
5
Indications for Dialysis
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A acidosis
E electrolyte abnormalities
I intoxication/poisoning
O fluid overload
U uremia symptoms/complications
Dialysis for Intoxications
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T theophylline
A aspirin
B barbiturates
L lithium
E ethylene glycol, methanol
M Metformin
Peritoneal Dialysis
Cuffed
Tunnelled
Hemodialysis
Catheters.
Relative Contraindications
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Alzheimer’s disease
Multi-infarct Dementia
Hepatorenal syndrome
Advanced cirrhosis with encephalopathy
Advanced malignancy
HIV with dementia
Cardiovascular events by Stage of
CKD
NKF KDOQI guidelines www.kidney.org/professionals/KDOQI/guidelines_ckd/toc.htm
All Cause Mortality By Stage of
CKD
NKF KDOQI guidelines www.kidney.org/professionals/KDOQI/guidelines_ckd/toc.htm
Risk Factors for Contrast
Nephropathy
• Age over 60
• Diabetes
• Pre-Renal States
– CHF
– NSAIDS, ACE Inhibitors, Diuretics
• Proteinuria Includes, but not limited to
Myeloma.
• Pre-existing Renal Disease
Risk of CN By Stage of CKD
100
90
80
70
60
Dialysis
ARF
50
40
30
20
10
0
Stg 5
< 20 ml/min
Stg 4
20 – 30
Stg 3
30 – 60
Stg 2
> 60
Incidence of CN
• Nationally
4%
• GVH 2005
• GVH 2006
18%
5
• DHH
4%
Contrast Nephropathy at GVH
2005
%
50 50
% CIN
40 40
30 30
20 20
10 10
0
0
All pts
All pts
DM
DM
CHF
CHF
Proteinuria
Proteinuria
CRF
CRF
Policy / Recommendations
• Stop ACE/ ARB, NSAIDs, Diuretics day before procedure
• IVF for everyone
– NS for low risk pts
– Bicarb for high risk pts?
• Urinalysis for all pts/ calculate Creat Clear for all pts.
– Proteinuria or creat clear < 40 considered High risk.
• Mucomyst for High risk pts
• Limit volume of contrast in High Risk Pts.
• Consider Nephrology consult if considering Mannitol,
Corlepam, or identified as high risk.
Contrast Nephropathy GVH
2006
• After Implementation of Policy
%
% CIN
25
25
20 20
15 15
10 10
5
5
0
0
All pts
DM
All pts
DM
CHF
CHF
Proteinuria
Proteinuria
CRF
CRF
Percentage of Adults With Diabetes
Who
Achieved Recommended Levels of
Vascular
100
90
Risk Factors in NHANES NHANES III
80
NHANES IV
70
%
60
50
40
30
20
10
0
Hb A1c <7%
Saydah S et al. JAMA. 2004;291:335-342.
BP <130/80
mm Hg
TC <200
mg/dL
Good Control
of All Three
Correction of Anemia in Diabetic CHF
• Diabetic patients with Hb less than 12.5 g% treated
with erythropoetin and IV iron
– NYHA class improved by 36.8%
– Dyspnea improved by 69.7% on Visual Analogue Scale
– EF improved by 7.6%
– Hospitalizations decreased by 96.6%
Silverberg DS et al. Nephrol Dial Transplant. 2003;18:141-146.
Advances in Artificial Kidneys
• Membraneless artificial kidney
– Uses fluid layer in microtubule for solute
exchange
– Worn on arm, connected to avf continuously
– The fluid layer collects wastes and is
exchanged periodically
– Infoscitex Inc and Columbia University
– Reach market in 2012
Wearable Artificial Kidney
• Miniaturized dialysis machine worn around
waist. Wt 5 lbs.
• Utilizes a unique battery powered pump
for blood and dialysate
• Sorbent cartridge based dialysate
• Already proven for SCUF in CHF pts.
• UCLA Victor Gura, MD
Human Nephron Filter
• Nanomembrane technology
• May be able to tailor dialysis
• Would lend itself to wearable, continuous
modalities
• Philtre, Alan Nissenson, MD
Bioartificial Kidney
• Uses cloned renal tubular cells from
unusable donor kidneys
• Cells line capillary tubules in a kidney
similar to conventional dialysis kidney
• Renal Assist Device can assume
endocrine and metabolic functions
• In phase II study reduced mortality in ICU
ARF pts from 61 to 34 %.
• University of Michigan David Humes, MD
Dose of Dialysis Matters
• Improved survival in several studies with
higher dialysate flow rate with CVVHDF
– Ronco uses 35 ml/kg/hr
• Lancet 2000;356:26-30
• Kid Int 2006;70.
• Daily intermittent dialysis reduced mortality
and hastened renal recovery
• NEJM 2002;346:305-310.
A new equation to estimate
GFR
• BF creat less than 0.7:
– GFR=166 X (Scr/0.7)-0.329 X (0.993)age
• BF creat over 0.7:
– GFR=166 X (Scr/0.7)-1.209 X (0.993)age
• BMale creat less than 0.9:
– GFR=163 X (Scr/0.9)-0.411 X (0.993)age
• BMale creat over 0.9:
– GFR=163 X (Scr/0.9)-1.209 X (0.993)age
A new equation to estimate
GFR
• Non AA F creat less than 0.7:
– GFR=144 X (Scr/0.7)-0.329 X (0.993)age
• Non AA F creat over 0.7:
– GFR=144 X (Scr/0.7)-1.209 X (0.993)age
• Non AA Male creat less than 0.9:
– GFR=141 X (Scr/0.9)-0.411 X (0.993)age
• Non AA Male creat over 0.9:
– GFR=141 X (Scr/0.9)-1.209 X (0.993)age
Levey,Stevens et al. A New Equation to estimate GFR. Ann Int Med.2009;150:604-12.
A New Equation To Estimate
GFR
• MDRD overestimates normal renal
function population and underestimates
low GFR.
• This method tends to overestimate less.
– By 2.5 ml/min vs 5.5 ml/min average
– By 3.5 ml/min vs 10.6 ml/min for pts with GFR
over 60.
Welcome to Hell
Here’s your pager!
Reason for Nephrology
Consultation
25%
ARF
15%
Fluid & Lytes
Other
60%
Ref: Paller Sem Neph 1998, 18(5), 524.