Identifying Chronic Kidney Disease (CKD) Advantages and Pitfalls of the Current Classification System. Risk Factors. Costs of CKD.

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1 Identifying Chronic Kidney Disease (CKD) Advantages and Pitfalls of the Current Classification System Risk Factors Costs of CKD End of Life Mark D. Purcell DO Nephrology/Internal Medicine Carolina Nephrology, PA 203 Mills Avenue Greenville, SC (864)

2 Objectives Identify patients with chronic kidney disease (CKD), the staging of CKD, and recognize the challenges and limitations with the current classification system. Identify risk factors in the development and progression of CKD as well as associated complications including death. Recognize that early recognition of progressive CKD, with appropriate management and early referral, should lead to both clinical and economic benefits.

3 Case 56 y/o white female with hx of DM presents as a new patient to your office Vitals: BP: 165/102 HR: 80 PE/ROS otherwise unremarkable UA reveals proteinuria Creatinine of 1.2 mg/dl Does this patient have CKD?? How severely compromised is her renal function? Is creatinine an acceptable marker Etiology: DM vs. HTN

4 Objectives Identify patients with chronic kidney disease (CKD), the staging of CKD, and recognize the challenges and limitations with the current classification system. Identify risk factors in the development and progression of CKD as well as associated complications including death. Recognize that early recognition of progressive CKD, with appropriate management and early referral, should lead to both clinical and economic benefits.

5 Figure i.4 Temporal trends in CKD prevalence, overall and by CKD stage, among Medicare patients age 65+, Data Source: Medicare 5 percent sample. This graphic also appears as Figure 2.1. Vol 1, CKD, Ch i

6 Definition Of CKD There are two independent criteria for CKD: Kidney damage for 3 months structural or functional abnormalities of the kidney, with or without decreased GFR, manifest by either: pathological abnormalities; or markers of kidney damage, including abnormalities in the composition of the blood or urine; or abnormalities in imaging tests. GFR < 60 ml/min/1.73m2 for 3 months, with or without kidney damage.

7 Pathologic Abnormalities By Radiology (US, CT, MR, etc.) Multiple cysts consistent with polycystic kidney disease (PKD) Extensive scarring Small kidneys--but be careful of the term medical renal disease Renal masses or cysts that are not simple should be referred to a urologist By Histology--i.e., renal biopsy

8 Markers of Kidney Damage Electrolyte and other abnormalities due to tubular disorders Urine sediment abnormalities Proteinuria Microalbuminuria Hematuria (especially when seen with proteinuria) Isolated hematuria has a long differential: infection, stone, malignancy, etc. Casts (especially with cellular elements) History of kidney transplantation

9 Patient meets definition of Chronic Kidney Disease? YES NO Determine Stage of CKD Determine underlying cause Identify risk factors for progression Identify comorbidities Risk Factor Reduction

10 Creatinine Vs GFR Why Estimate GFR From SCr? Serum Creatinine Alone Is a Poor Indicator of Kidney Function

11 Why Estimate GFR From SCr, Instead of Using SCr for Kidney Function? Age Gender Race SCr (mg/dl) egfr (ml/min/1.73 m 2 ) CKD stage 20 M B * 20 M W * 55 M W * 55 F B F W * If pathological abnormalities or markers of kidney damage GFR calculator available at: B = black; W = all ethnic groups other than black.

12 Glomerular Filtration Rate (GFR) GFR is the best overall index of kidney function in health and disease. Normal GFR varies according to age, sex, and body size. Young adults ml/min/1.73 m 2 and declines with age. GFR can be estimated from prediction equations (egfr) MDRD Study (recommended by K/DOQI) Cockcroft-Gault formula

13

14 Stages of Chronic Kidney Disease (CKD) Stage Description GFR Action At increased risk 1 Kidney damage with normal or GFR 90 (with CKD risk factors) 90 Screening, CKD risk reduction Diagnosis and treatment, Treatment of comorbid conditions, Slowing progression, CVD risk reduction 2 Kidney damage with mild GFR Estimating progression 3 Moderate GFR Evaluating and treating complications 4 Severe GFR Preparation for kidney replacement therapy 5 Kidney Failure <15 (or dialysis) Replacement (if uremic) Adapted from NKF K/DOQI

15 Figure i.3 NHANES participants with CKD aware of their kidney disease, Data Source: National Health and Nutrition Examination Survey (NHANES), , & participants age 20 & older. Abbreviations: CKD, chronic kidney disease. This graphic also appears as Figure Vol 1, CKD, Ch i

16 MDRD egfr (ml/min/1.73 m 2 ) = 186 x (Creat/88.4) x (Age) x (0.742 if female) x (1.210 if AA) Limitations The MDRD Study equation is less accurate at GFR estimates greater than 60 ml/min/1.73 m 2 At levels of estimated GFR less than 60 ml/min/1.73 m2, the equation is accurate for most persons of average body size and muscle mass The MDRD Study equation has not been validated in children (age < 18 years) pregnant women elderly (age > 70 years) racial or ethnic subgroups other than Caucasians and African Americans individuals with normal kidney function who are at increased risk for CKD

17 Lab Results From 1995

18 Fast Forward to 2010

19 45 y/o female with cirrhosis

20 24 hour urine collection: 45 y/o with cirrhosis By MDRD egfr 53 ml/min/1.73 m 2 based on serum creatinine of 1.11 mg/dl

21 Definition of Proteinuria Nephrotic Range 3.5 g/day Overt Proteinuria > 300 mg/day Microalbuminuria mg/day Orthostatic Proteinuria

22 Objectives Identify patients with chronic kidney disease (CKD), the staging of CKD, and recognize the challenges and limitations with the current classification system. Identify risk factors in the development and progression of CKD as well as associated complications including death. Recognize that early recognition of progressive CKD, with appropriate management and early referral, should lead to both clinical and economic benefits.

23 Causes of Kidney Failure Diabetes Hypertension 24% Glomerulonephritis 37% 16% Polycystic Kidney Disease Other 19% 4% Diabetes is the Predominant Cause of Kidney Failure US Renal Data System 2005 Annual Data Report

24 Patient Characteristics Associated with Increased Rate of GFR Decline Nonmodifiable African American race Female gender Old age Lower baseline level of kidney function Modifiable Higher level of proteinuria Higher BP Poor glycemic control Smoking

25 2 nd study out of Kaiser Permanente Analyzed outcomes in 1,120,295 adults with CKD. Median follow up 2.84 yrs. Cardiovascular events 15 followed stepwise 10 5 progression > <15 Death from any cause Cardiovascular disease Most patients died of cardiovascular causes Majority of CKD patients died before ending up on dialysis. 2004,351:

26 Figure i.7 Unadjusted and adjusted all-cause mortality rates (per 1,000 patient years at risk) for Medicare patients aged 66 and older, by CKD status and year, (A) Unadjusted (B) Adjusted Data source: Medicare 5 percent sample. January 1 point prevalent Medicare patients age 66 and older. Adj: age/sex/race/prior year hospitalization/comorbidities. Ref: 2012 patients. Abbreviations: CKD, chronic kidney disease. This graphic also appears as Figure 3.1. Vol 1, CKD, Ch i

27 Objectives Identify patients with chronic kidney disease (CKD), the staging of CKD, and recognize the challenges and limitations with the current classification system. Identify risk factors in the development and progression of CKD as well as associated complications including death. Recognize that early recognition of progressive CKD, with appropriate management and early referral, should lead to both clinical and economic benefits.

28 Stages in Progression of Chronic Kidney Disease and Therapeutic Strategies Complications Normal Increased risk Damage GFR Kidney failure CKD death Screening for CKD risk factors CKD risk reduction; Screening for CKD Diagnosis & treatment; Treat comorbid conditions; Slow progression Estimate progression; Treat complications; Prepare for replacement Replacement by dialysis & transplant AJKD 2002: 39(2)

29 CKD Intervention: Clinical Action Plan BP control, ACEI/ARB Stage 1-2 Stage 3 Stage 4 Stage 5 GFR > <15 Glycemic control CVD risk reduction: Dyslipidemia management, Tobacco cessation Avoid NSAIDS/Contrast Anemia Nutrition Renal bone disease Vascular access & Transplantation

30

31

32

33 Preparation for Renal Replacement Therapy Pre-emptive transplantation ESRD options/education ESRD outcomes

34 Hemodialysis

35 Peritoneal Dialysis

36 Case 56 y/o white female with hx of DM presents as a new patient to your office Vitals: BP: 165/102 HR: 80 PE/ROS otherwise unremarkable UA reveals proteinuria Creatinine of 1.2 mg/dl Does this patient have CKD?? How severely compromised is her renal function? Is creatinine an acceptable marker Etiology: DM vs. HTN

37 Case : Suggestive findings 56 yr old W female hx DM, uncontrolled HTN with a cr 1.2 mg/dl and dipstick positive for 1 + proteinuria Suggestive of Diabetic Nephropathy: evidence of microvascular complications like retinopathy, neuropathy, large kidneys, macroalbuminuria or microalbuminuria plus retinopathy or > 10 yr of type 1 diabetes with microalbuminuria Suggestive of Hypertensive Nephrosclerosis: long history of hypertension with retinopathy, left ventricular hypertrophy, small kidneys, slowly progressive renal insufficiency, gradually increasing non-nephrotic proteinuria

38 Referral Decision Making By GFR and Albuminuria COMPLIMENTS OF: * Referring clinicians may wish to discuss with their nephrology service depending on local arrangements regarding monitoring or referring. Source: KDIGO 2012 Clinical Practice Guideline for the Evaluation and Management of CKD. Volume 3, Issue 1, January Reproduced with permission of Kidney Disease Improving Global Outcomes (KDIGO) /

39 Early vs. Late Referral: Consequences and Benefits Consequences of late referral Anemia and bone disease Severe hypertension and fluid overload Low prevalence of permanent access Higher initial hospitalization rate Higher 1-year mortality Less patient choice of dialysis modality choice Worse psychosocial adjustment Benefits of early referral Delay need to initiate dialysis Higher proportion of permanent access Greater choice of treatment options Reduced need for urgent dialysis Reduced hospital LOS and cost Improved nutritional status Better management of CVD and comorbid conditions Higher patient survival

40 Kidney Wellness Center

41 Components of Carolina Nephrology Kidney Wellness Center Disease Monitoring Integration with other chronic disease management programs including DM, HTN, and CHF Rx management and dietary advice Anemia Management Vaccination programs Information and psychosocial support Renal replacement therapy education (HD, PD, and transplant) Advanced care planning and end-of-life care (where appropriate)

42 Overall expenditures on Parts A and B services for the Medicare population age 65+ and for those with CKD, by year, Data source: Medicare 5 percent sample. Abbreviations: CKD, chronic kidney disease. Vol 1, CKD, Ch 6

43

44 Summary Optimal Management of the Rising Creatinine Screen Spot urine albumin microalbumin to creatinine ratio Estimate GFR from serum creatinine using the MDRD prediction equation Delay Progression BP control ACE-I/ARB Blood sugar control? Protein restriction in advanced disease Treat Comorbidities Anemia Mineral and Bone Disorder Hyperlipidemia Cardiovascular disease Nutrition, Acidosis Preparation for renal replacement

45 Questions/Comments Mark D. Purcell DO Nephrology/Internal Medicine Carolina Nephrology, PA 203 Mills Avenue Greenville, SC (864)

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