Objectives. For more information. Renal Disorders for the Primary Care Provider: Updates and When to Refer 3/30/2012

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1 Renal Disorders for the Primary Care Provider: Updates and When to Refer Dr. Julie Isaac Southern Kentucky Nephrology Associates May 4, 2012 Objectives How to evaluate common nephrologic diseases in the primary care setting Deciding when to refer to Nephrology Understanding how the nephrologist can be beneficial to your patients with chronic kidney disease For more information All images in the presentation are courtesy of the web site 1

2 Case 1-Hematuria AJ is a 61 year old WM with HTN, hyperlipidemia and a 40 pack year history of smoking. He presents for routine office visit with BP 135/85, benign physical exam and UA with 3+ blood and 1+ protein. His creatinine is 1.1 mg/dl. What is the next step? Hematuria work-up Urine for microscopy and cytology Repeat UA Urine culture CBC,CMP, PT/PTT Renal ultrasound and/or CT of the abdomen Referral to Urology Urology work-up is negative. What is the next step? 2

3 Refer patient to Nephrology 24 hour urine reveal 450 mg of protein and serologic work-up is negative. Creatinine has increased from 1.1 mg/dl to 1.7 mg/dl. Renal biopsy is performed and reveals IgA nephropathy Most Common Nephrologic Causes of Hematuria IgA Nephropathy Thin basement membrane disease Mesangioproliferative glomerulonephritis Alport s syndrome Post-infectious GN 3

4 Case #2-Proteinuria S.M. is a 33 yo AAF with a history of type 2 diabetes for 3 years, HTN, and obesity. She has previous normal UA and normal creatinine. On routine office visit she complains of edema and bubbly urine and UA reveals 4+ protein. Creatinine is 0.8 mg/dl and HgbA1C is 7.2%. What is the differential? Work-up of Proteinuria Spot urine for protein and creatinine Urine for microscopy 24 hour urine for protein Serologic work-up including lupus panel, Hepatitis studies, HIV, SPEP and UPEP Renal Ultrasound Work-up of Proteinuria Nephrotic syndrome is proteinuria > 2000 mg on 24 hour urine All patients with nephrotic syndrome should be referred to nephrology 4

5 Complications of Nephrotic Syndrome Edema Protein malnutrition Hypovolemia Thromboembolisn Hyperlipidemia Increased risk of infection Most Common Causes of Proteinuria Diabetic nephropathy Focal and Segmental Glomerulosclerosis Membranous Nephropathy Minimal Change Disease Amyloidosis Case #2 Proteinuria continued 24 hour urine reveals 4.2 gm of protein and serologies show an ANA 1:320 with low C3 and C4 levels. Renal biopsy performed and reveals focal proliferative lupus nephritis. What would nephrologist do if serologies were negative and 24 hour urine revealed 850 mg of protein? 5

6 Case #3-Acute Renal Failure BR is a 62 year old with long-standing HTN and alcohol abuse who has a baseline creatinine of 1.6 mg/dl. On routine labs, his creatinine increased to 4.5 mg/dl. His home medications include Olmesartan/HCTZ, folic acid, Pantoprazole and Metoprolol. What s the next step? Acute Renal Failure in the Outpatient Setting Pre-renal: Volume depletion/hypotension Vascular: Vasculitis, RAS, atheroemboli, malignant HTN Glomerular disease Tubular and Interstitial Diseases: ATN,AIN Obstructive Uropathy Case #3-ARF continued BR had negative UA, normal renal ultrasound and PVR Olmestartan/HCTZ was discontinued and by the time patient saw me, his creatinine had improved to 2.1 mg/dl 6

7 UA Simple Tests to Work-up ARF Spot urine for sodium Fractional excretion of sodium Orthostatics Renal U/S and PVR Stop medications Diabetic Nephropathy Hyperfiltration during early part of disease Initially microalbuminuria ( mg/d) Subsequent macroalbuminuria (>300 mg/d) Microscopic hematuria possible Frequently associated with retinopathy Risk factors include HTN, increased HgbA1C, African American race, obesity, smoking 7

8 Treatment of Diabetic Nephropathy Strict glycemic control ACE I in type I diabetes ARB or ACE in type 2 diabetes Strict BP control (<130/80) Weight reduction Treatment of hyperlipidemia Protein restriction? 8

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10 Hypertension Treat only if SBP>140 and/or DBP>90 after 3 or more visits Treat DM, CKD and cardiovascular disease with SBP>130 and/or DBP>80 Try lifestyle modification first Do 24 hour ambulatory BP monitoring for patients with normal BP at home but elevated BP in office Lifestyle Modification Weight reduction DASH diet Sodium restriction Aerobic activity Decrease alcohol consumtion Stop smoking Individualizing Antihypertensive Therapy Systolic CHF- ACE/ARB, beta blocker, diuretic Post MI-ACE, BB, aldosterone antagonist Proteinuric CKD-ACE/ARB Atrial arrhythmias- BB, non-dihydropyridine CCB Diabetes without proteinuria-diuretic, ACE 10

11 Chronic Kidney Disease (CKD) CKD is either GFR<60 ml/min or urinary albumin excretion>30 mg/d for 3 or more months CKD is associated with a substantial increase in cardiovascular disease 11

12 When to Refer to Nephrology If GFR<60 ml/min If Spot urine protein to creatinine ratio is >300 mg/g GFR declining by >30 % in 4 months without obvious cause K>5.5 without known cause Resistant HTN If you or the patient are nervous! What to limit or avoid in CKD IV contrast Dehydration Hypotension Gadolinium if GFR <30 ml/min NSAIDs Bactrim 12

13 Complications of CKD Volume overload Hyperkalemia Metabolic acidosis Hyperphosphatemia Renal osteodystrophy Hypertension Anemia Hyperlipidemia Preparing for ESRD AV fistulas are preferred vascular access and may take 6 months to mature AV grafts usually mature in 2 weeks, but are more prone to infection and clotting Peritoneal catheters are ready to use within 2 weeks Cuffed tunneled catheters may be used immediately but have much higher risk of infection and venous stenosis ABSOLUTE Dialysis Indications A-Refractory acidosis E-Refractory electrolyte imbalances I-Intoxication (Overdoses) O-Volume overload U-Uremic pericarditis, uremic encephalopathy 13

14 Renal Transplantation Is the treatment of choice for ESRD if patient is a candidate Patient can begin to accrue wait time on the transplant list when GFR is <20 ml/min Living donors can begin work up prior to patient being dialysis dependent Take Home Points regarding CKD 26 million American adults have CKD and millions of others are at increased risk. Early detection can help prevent the progression of kidney disease to kidney failure. Cardiovascular disease is the major cause of death for all patients with CKD. Early referral to a nephrologist can help improve survival. 14