objectives management of ckd and complications in primary care · medicare and private insurers for...
TRANSCRIPT
8/10/17
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ManagementofCKDandComplicationsinPrimaryCare
DeniseKLink,MPAS,PA-CTheUniversityofTexasSouthwesternMedicalCenter
AmericanAcademyofNephrologyPAsNationalKidneyFoundationCouncilofAdvanced
PractitionersAmericanAcademyPAliaisontoRenalPhysicians
NothingtoDisclose
Objectives• Recognizetreatmentgoalsforpreventingthe
progressionofCKDtowardESRDbyloweringbloodpressureandproteinuriatocurrentguidelinesthroughdietarychangesandinitiatingRAASblockademedication(s)
• InterpretthemostrecentguidelinesforbloodpressureofCKDpatients,goalsforDMwithCKD,treatmentsforCKDwithandwithoutproteinuria,ageofaCKDpatient,andco-morbiditiesofCKD
• DiscusshowtomanagethecomplicationsassociatedwiththetreatmentofCKD,includinghyperkalemia,fluidoverload,metabolicacidosisandproteinuria
ARS#1
WhichpatienthasaworseprognosisforCKDprogressiontoESRD?a) 75yoHTNeGFR 40ml/min,UACR150mg/gb) 22yoSLEeGFR 80ml/min,UACR3000mg/gc) 35yoADPKDeGFR 65ml/min,UACR100mg/gd) 55yoT2DMeGFR 50ml/min,UACR1500mg/
ARS#2
45yoobese,T2DM,DLD,CAD,HTN,hyperuricemia,CKDpresentswithworseningofrenalfunction.SCr increasedto2.0mg/dl.eGFRdecreasedfrom58to42ml/min. UACR2000mg/g.A1C8.5%.Youwould_____andrefertoendocrinology.a) Continuemetformin1000mgBIDb) Decreasemetformin500mgBIDc) Discontinuemetformin
ARS#3
65yomalewithT2DM,uncontrolledHTNandCKDpresentswithBP175/60,P80,BMI35.Scr 2.4mg/dl,eGFR 32ml/min,K4.8mEq/LA1c9.8%,UACR2,550mg/gMeds:MetoprololXL50mgdaily,HCTZ25mgdailyandinsulin• Whatbloodpressuremedicationchangeswouldyou
initiallymaketoachieveoptimalBPgoalto<130/80?a) DiscontinueHCTZandstartfurosemideb) IncreasemetoprololbasedonHRc) StartACEIorARBd) Alloftheabove.Isthisatrickquestion?
Numerous,sometimesconflictingCKDguidelinesà challengesprovidingappropriatecare
ManagingCKDinPrimaryCare
Making Sense of CKD
§ Designed to help PCPs manage adult CKD patients
§ Emphasizes key considerations for evaluating and managing CKD patients:
§ Identifying patients at highest risk for progression to kidney failure
§ Slowing progression among these high-risk patients
§ Highlights useful resources:
§ Patient education materials
§ Clinical tools
§ Professional reference materials
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RoleofPCPinCKDManagement
Nephrologyworkforce(n=7020)insufficientPCPscareformajorityofpatientswithCKDprovidingopportunitiesfor:• IdentificationofpatientsatriskforCKD• EarlyrecognitionofCKDanditsseverity• IdentificationandmanagementofCKDrisks• Engagementofpatientsinriskfactormodification• Timelyreferraltonephrologyandeffectivecare
coordination“Thebettertheprimarycare,thegreaterthecostsavings,thebetterthehealthoutcomes,andthegreaterthereductioninhealthand
healthcaredisparities”BarbaraStarfield,MD,MPH
PublicHealthBurdenofESRD
• Over600,000USadultshaveESRD
• Costoftreatment:- $75,000perperson/year
-ESRDcosttakesup6%ofMedicarebudgetdespitemakingup1%ofMedicarepopulation
• Associatedwithpoorsurvivalandqualityoflife
USRDS2013/14AnnualDataReport
PublicHealthBurdenofCKD• Averageestimatedall-causecostperpatentin2016:ComparingstandardofcarewithRAASinthosewithoutCKDtothosewithCKD.93,912<65yoand81,829>65yo
• Newresearchshowsthattheall-causecoststoMedicareandprivateinsurersfortreatingCKDpatientsrapidlyincreaseasthediseaseprogresses.
CommercialInsurance Medicare
NoCKD $7500 $8100
Stage3a CKD(GFR45-59ml/min)
$27,200 $20,500
Stage4-5 CKDGFR(0-29ml/min)
$77,000 $46,100
Golestaneh,etal.“HealthcareCostRisesExponentiallybyStageofChronicKidneyDisease”(KidneyWeek2016,Abstract2289)
1,120,295AmbulatoryAdults
Goetal.N.Engl.J.Med351:1296,2004
36.60
21.80
11.29
3.652.11Ra
teofC
ardiov
ascular
Even
ts(p
er100
person-yr)
EstimatedGFR(ml/min/1.73m2)
No.ofEvents 73,108 34,690 18,580 8809 3824
≥60 45-59 30-44 15-29 <15
10
40
15
30
35
20
25
0
5
RateofD
eathfrom
Any
Cau
se
(per100
person-yr)
≥60 45-59 30-44 15-29 <15
EstimatedGFR(ml/min/1.73m2)
No.ofEvents25,803 11,569 7802 4408 1842
14.14
11.36
4.76
1.080.76
1514131211109876543210
1501401301201101009080706050403020100
144.61
86.75
45.26
17.2213.54RateofH
ospitalization
(per100
person-yr)
EstimatedGFR(ml/min/1.73m2)
No.ofEvents366,757 106,543 49,177 20,58111,593
≥60 45-59 30-44 15-29 <15
Death CVEvents Hospitalization
PublicHealthBurdenofCKDAssociatedwithPoorClinicalOutcomes
PatientAwarenessofCKDislow
USRDS2014AnnualDataReport
LifetimeIncidenceofCKDStages3-5intheUSis59%*
A60%chanceofhaveCKDisequivalenttosayingthat80%ofAmericanswilldevelopoldage.Toughbuttrue.
PaulW.Eggers,PhDProgramDirectorforKidneyandUrologyEpidemiologyNationalInstituteofDiabetesandDigestiveandKidneyDiseases
*GramsME,ChowEKH,Segev DL.LifetimeincidenceofCKDStages3-5intheUnitedStates.AmJKidneyDisease,2013
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ESRD=KidneyFailure
100
80
60
40
20
ProgressiveKidneyDisease
Time(yrs)2 4 6 810
Normal(0.8ml/min/yr)
30yearold
Requires Repeated Measures of GFR Over Time
DiseaseProgressionofCKD SadieCKDorAGING?
85y/oNIDDM
eGFR 45ml/min
Ifyoulose1%/yr abovetheageof30,
85y/o=55yearsofGFRlossOr
100-55or45ml/min
ESRDTreatmentsDialysisandTransplantation
Peritoneal Dialysis(PD)usestheperitonealliningtofiltertheblood
Hemodialysis(HD)usesamachineandfiltersthebloodoutsidethebody
“PatientswithCKD,particularlythosewithESRDareamongthemostsymptomaticofanychronicdiseasegroup.”
Murtagh F,Weisbord S.Symptomsinrenaldisease.InChambersEJetal(eds)SupportiveCarefortheRenalPatient 2010,2nd ed,OUP.
TheESRDPatient
• Substantial impaired health-relatedqualityoflife• Tremendoussymptomburden• Thenumberandseverityofphysicalandmentalsymptomsaresimilartothoseofmanycancerpatientshospitalizedinpalliativecaresettings
• Symptomsincludepain,insomnia,nausea,anorexia,pruritus,severefatigueandSOB
• Unlike manycancer patients,thesesymptomsareoftenpresentforseveralYEARS
PredictorsofAdverseRenalandCardiovascularOutcomes
• Age
• Hyperglycemia
• Hypertension
• Albuminuria
• ActivationofRAAS
• FamilyHistory(renal)
• Ethnicity
• Race
• Hypoalbuminemia
• NT-proBNP/TroponinT
• C-reactiveprotein
• Smoking1.Keaneetal.Kid.Int.2003,63:1499-15072.Parving etal.KidInt69:2057–2063,20063.McMurrayetal.AmHeartJ.2011Oct;162(4):748-7554.Desaietal.AmJKidneyDis.2011Nov;58(5):717-28.
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CriteriaforCKDWhereistheSCr?
1. DecreasedGFR≤60ml/minfor>3months
2.MarkersofKidneyDamagefor>3months• Albuminuria≥30mg/g(UACR)• Urinarysedimentabnormalities
Ex:microhematuria• Electrolyteandotherabnormalitiesduetotubular
disorders• Structuralabnormalitiesdetectedbyimaging
Ex:ADPKD(polycystickidneydisease)• Historyofkidneytransplantation
or
WhichGFR?• Glofil=true/accurateGFR• eCrCl usingCockcroft-Gaultformula• eGFR usingModificationofDietin
RenalDisease(MDRD)formula• eGFR usingtheCKD-EPIformula• eGFR usingtheMayoQuadraticformula• eGFR forchildrenusingSchwartzformula• CystatinC• CreatinineClearance(CrCl)
NotenoughvariabilitytochangeStageofKidneyDisease
CKDStageswithPrognosis
KDIGO2012ClinicalPracticeGuidelinefortheEvaluationandManagementofCKD,KidneyInternational,Jan2013,Vol 3,Issue1
Primaryfocalandsegmentalglomeruloscleorosis(nephroticproteinuria)
Type2diabetes(20-40%)
Remuzzi,G.etal.J.Clin.Invest.116:288-296,2006
GFR(m
l/min)
0
20
40
120
60
80
100
400 302010Timeafterdiagnosis(yr)
ADPKD(PKD1 mutation)
DeclineinGFRvariesbyDiseaseState,FromPatienttoPatientandisAccelerated
inthosewithAlbuminuria
AlbuminuriaIsaPrognosticIndicator
ProteinuriaandRateofChangeinKidneyFunctioninaCommunityBasedPopulation,JASM2013
TheProgressionofCKD:A10-yearpopulation-basedstudyoftheeffectsofgenderandage.KI2006
TherelationshipbetweenmagnitudeofproteinuriareductionandtheriskofESRD:ResultsoftheAASKstudyofkidneydiseaseandhypertensionAchInternMed2001
CombiningGFRandalbuminuriatoclassifyCKDimprovespredictionofESRD,JASN2009
AlbertaKidneyDiseaseNetwork:Relationbetweenkidneyfunction,proteinuria,andadverseoutcomes,JAMA2010
PrevalenceofCKDComplications
Moranne O.etal.JAmSoc Nephrol 20:164-171,2009.
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SignsandSymptoms
• DecreasingGFR• Increasingalbuminuria• UncontrolledHTN• ImprovedDMmanagement(Why?)
• Hyperkalemia• Metabolicacidosis• Anemia• Hyperphosphatemia• Hyperparathyroid• Hypovitaminosis D
• Nausea,vomiting,poorappetite,weightloss
• Troublesleeping• Fatigue• Nocturia• Dry,itchyskin• Legcramping(night?)• Skincolorchanges• SOB• Edema• Confusion
ManagementofCKD
1. Screenatriskpatients2. DeterminelevelofrenalfunctionwitheGFR3. Determineprognosiswithalbuminuria4. AddRAASblockadeifalbuminuriaispresent5. Bloodpressuretogoal?6. DiabetesA1C?7. Smokingcessation8. Weightloss9. LimitingfutureAKI
CKDRiskFactors
• Diabetic• Hypertensive• Olderage(>60y/o)• RecurrentUTI• Kidneystones• HistoryofAKI• Autoimmunedisease:Lupus,Sjogrens,RA,MCTD…
• FamilyhistoryofCKD• CVD• Neoplasm:multiplemyeloma,Wilms,kidneycancer
• Previoustransplant• Previouskidneydonor
1.KDOQIguidelines20022.http://www.uspreventiveservicestaskforce.org/uspstf/uspsckd.htm
ManagementofCKD
1. Screenatriskpatients2. DetermineandtrendrenalfunctionwitheGFR3. Determineprognosiswithalbuminuria4. AddRAASblockadeifalbuminuriaispresent5. Bloodpressuretogoal?6. DiabetesA1C?7. Smokingcessation8. Weightloss9. LimitingfutureAKI
45y/owhiteFemaleeGFR39Stage3b
17y/onon-whiteMaleeGFR80Stage1
70y/owhiteFemaleeGFR 30
Stage3b/borderline4
70y/onon-whiteMaleeGFR60Stage2
HoldSCrstableat1.5
WhatistheGFR?
R.K.isa53yomalewhohasadvancedliverdiseaseandnephroticproteinuria
Scr0.55mg/dl eGFR 177ml/min 20030.63mg/dl 20040.77mg/dl 20050.86mg/dl 20061.2mg/dl eGFR63ml/min 2008
TrendingRenalFunction:eGFR/Scr
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ManagementofCKD
1. Screenatriskpatients2. DetermineandtrendrenalfunctionwitheGFR3. Determineprognosiswithalbuminuria4. AddRAASblockadeifalbuminuriaispresent5. Bloodpressuretogoal?6. DiabetesA1C?7. Smokingcessation8. Weightloss9. LimitingfutureAKI
ProteinuriavsAlbuminuria
MorningUACR
UACR>30and<300mg/gModeratealbuminuria
UACR300mg/gSeverealbuminuria
Confirmedwithin3months
InterventionàTx:1.AddACEi ORARB2.LowerBP<130/803.BeginlowSodiumdiet
Monitorq3-6months
Unconfirmed
Monitorannually
EvaluationofAlbuminuria
SpecialThankstoScottandWhiteofTempleTXforuseoftheirkidneycomic
Urineproteintocreatinineratio(UPCR)
24hoururinefortotalprotein
Urinealbumintocreatinineratio(UACR)
UrinaryproteinOralbumin
QuantifyingALBUMINURIA:WhereistheUAdipstick?
ManagementofCKD
1. Screenatriskpatients2. DetermineandtrendrenalfunctionwitheGFR3. Determineprognosiswithalbuminuria4. AddRAASblockadeifalbuminuriaispresent5. Bloodpressuretogoal?6. DiabetesA1C?7. Smokingcessation8. Weightloss9. LimitingfutureAKI
ASSKStudy
AlbuminuriamoredetrimentaltohypertensiveblackpatientsLongactingARBmoreeffectivethanshort.Costvssideeffects
Takingthemedicationworksbetterthannot,NOmatterwhichdrug!
RAASBlockade
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Aldosterone
+
Inhibition ofRAAS:leadstolessproteinuria1.ACEIs• Blockconversionofangiotensin I
toangiotensin II• Increaseavailabilityofbradykinin
2.ARBs• Selectivelyantagonizeangiotensin II• Mayalsomodulatetheeffectsof
angiotensin IIbreakdownproducts
WeirMR.Clin Ther.2007;29(9):1803-1824.
Renin
Angiotensinogen Angiotensin IACE
Angiotensin II
Renin-Angiotensin-AldosteroneSystem(RAAS)
RAAS inhibition provides nephroprotectionindependent of blood pressure lowering
2000
20
2
200
Albu
minuria(µ
g/min)
40%
60%Normoalbuminuria
Overtnephropathy
Microalbuminuria
Time(Years)
IDNT
RENAAL
IRMA2
ΔGFR2-20:10
ΔGFR1-3
ΔGFR1
BENEDICT
ROADMAP
Parving etalNewEngl.J.Med 2001,LewisetalNewEngl.J.Med 2001,BrenneretalNewEngl.J.Med 2001,Ruggenenti etalNewEngl.J.Med 2004
BlockadeoftheRAASSlowsorPreventsOnsetandProgressionofDiabeticKidneyDiseaseinHypertensiveType2Diabetics
ACEi orARBsevenwithAdvancedCKD
20-30%bumpinSCrisnormal.Thisshouldbeexpected.Repeatlabsin2weeks
ACEi + ARB=DualBlockadeEfficacyandsafetyofdualblockadeoftherenin-angiotensin
system:meta-analysisofrandomizedtrials Jan2013
DualBlockademeans- IncreasedriskofComplicationsAnd
Nodecreaseinmortality
Complicationsinclude:Hyperkalemia,hypotension,andkidneyfailure
ACEInhibitorandAngiotensinReceptor-IIAntagonistPrescribingandHospitalAdmissionswithAcuteKidneyInjury:ALongitudinalEcologicalStudy
IncreasedriskofAKIwithACEi/ARB
StrategiestoLowerAlbuminuriaMulti-RiskFactorInterventions
1. ControlBPtogoalof<130/80.(MDRD,ABCDAASK)LoweringBPbyitselfwillreducealbuminuriaby~50%orpreventsthe2-3x↑inalbuminuriaobservedinpatientwithusualBPgoal
2. BlockageofRAAS3. RestrictNaCl intake.Highsodiumintakewill
overrideanti-albuminuric effectsofACEi/ARBs4. AldosteroneantagonisticTx:spironolactone5. Smokingcessation6. Reduceobesity
ManagementofCKD
1. Screenatriskpatients2. DetermineandtrendrenalfunctionwitheGFR3. Determineprognosiswithalbuminuria4. AddRAASblockadeifalbuminuriaispresent5. Bloodpressuretogoal?6. DiabetesA1C?7. Smokingcessation8. Weightloss9. LimitingfutureAKI
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130 134 138 142 146 150 154 170 180
r=0.52;P <0.01
SystolicBloodPressure(mmHg)
DeclineinGFR
from
Baseline
(ml/min/year) Untreated
HTN
0
-2
-4
-6
-8
-10
-12
-14
ModifiedfromBakrisGLet.al.AmJKidneyDis,Sept.2000
Trialsincluded:MDRD,RENAAL,IDNT,AIPRI,CaptoprilTrail,REIN,AASK
LoweringBloodPressureSlowsProgressionofChronicKidneyDisease
IncidenceofallRenalEventsaccordingtoachievedBPlevels:ADVANCETRIAL
deGalanetal.JAmSocNephrol20:883–892,2009
RenalEvent=Newonsetorworseningalbuminuria,DoublingserumcreatinineandESRD
WhatBPTargetsshouldweStrivetoAchieve?
ComparisonofBPGuidelinesGuideline Population GoalBP
mmHgInitialdrugtreatmentoption
JNC8 General>60 yoGeneral<60yoDMCKD
<150/90<140/90<140/90<140/90
NB:thiazide,ACEi, ARBorCCBBL:thiazideorCCBDM:thiazide,ACEi,ARBorCCBCKD:ACEi orARB
KDIGO2012
CKDnoproteinuriaCKD+proteinuriaDM &CKDnoproteinuriaDM &CKD+proteinuria
<140/90<130/80<140/90<130/80
ACEi orARB
ACEi orARB
KDOQI2004
DM+CKDCKDwithproteinuriaCKDwithoutproteinuria
<130/80<130/80<130/80
ACEi/ARBACEiNopreference
NB-nonblack,BL-black,ACEi-angiotensinconvertingenzymeinhibitors,ARB-angiotensinreceptorblocker,CCB-calciumchannelblocker
LifestyleModification
Modification ApproximateSBPreduction
Weightreduction 5–20 mmHg/10kgwt loss
AdoptDASHdiet 8–14mmHg
Dietarysodium 2–8mmHg
Physicalactivity 4–9mmHg
Moderationofalcoholconsumption
2–4mmHg
Total=↓21mmHg
ManagementofCKD
1. Screenatriskpatients2. DetermineandtrendrenalfunctionwitheGFR3. Determineprognosiswithalbuminuria4. AddRAASblockadeifalbuminuriaispresent5. Bloodpressuretogoal?6. DiabetesA1C?7. Smokingcessation8. Weightloss9. LimitingfutureAKI
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A1CGoal7%
CKD4,5,5D=7.5%
MetforminDosing
USFoodandDrugAdministrationPrescribingGuidelinesforMetforminasRelatedtoKidneyFunctionMetforminiscontraindicatedin“renaldiseaseorrenaldysfunction(eg,assuggestedbyserumcreatininelevels≥1.5mg/dL [males],≥1.4mg/dL [females])orabnormalcreatinineclearance(CrCl).”Metformin“shouldnotbeinitiatedinpatients≥80yearsofageunlessmeasurementofcreatinineclearancedemonstratesthatrenalfunctionisnotreduced.”
TheNewFDAMetforminDosing
• PIstatesmetformincanbeuseduntilGFRof30ml/min(4/11/16)
• Basedonstudiesshowinglittlechanceoflacticacidosis
• Veryfewreportsoflacticacidosisin‘realpractice’– CollectedviaMedWatch (FDASafetyInformationandAdverseEventReportingProgram)
– Doyoureportknownsideeffectsofmedications?
StrategyMetforminRxinCKD
JAMA.MetformininPatientsWithType2Diabetes&KidneyDis:SystematicReview2014;312(24):2668-2675
ManagementofCKD
1. Screenatriskpatients2. DetermineandtrendrenalfunctionwitheGFR3. Determineprognosiswithalbuminuria4. AddRAASblockadeifalbuminuriaispresent5. Bloodpressuretogoal?6. DiabetesA1C?7. Smokingcessation8. Weightloss9. LimitingfutureAKI
ManagementofCKD
1. Screenatriskpatients2. DeterminelevelofrenalfunctionwitheGFR3. Determineprognosiswithalbuminuria4. AddRAASblockadeifalbuminuriaispresent5. Bloodpressuretogoal?6. DiabetesA1C?7. Smokingcessation8. Weightloss9. LimitingfutureAKI
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IatrogenicAKI Preventableevents→AKI→CKDprogression→ESRD
ComplicationsofCKD
1. Hyperkalemia2. Fluidoverload3. Metabolicacidosis4. Anemia5. Hyperparathyroid/hyperphosphatemia6. Depression7. Malnutrition
ComplicationsofCKD
1. Hyperkalemia2. Fluidoverload3. Metabolicacidosis4. Anemia5. Hyperparathyroid/hyperphosphatemia6. Depression7. Malnutrition
CasePresentation65yofemalewithCKDstage4,CAD,DMwithretinopathy,HTN,CHFandobesitywhopresentsfor3monthfollowupondiabetesmanagement.
• BP160/85,P60,weight250lbs• PErevealsS4and+1edema• LabsrevealedstableSCr 2.5mg/dl,BUN20,eGFR 20ml/min,Na+
140,K+6.5,CO220,spoturinealb/cr 2500mg/g.• Currentmeds:HCTZ25mgdaily,potassiumchloride20mEqBID,
lisinopril 40mgBID,labetalol300mgTID,ibuprofen400mgBID,spironolactone12.5mgBID
1. Whatarethepossiblecausesofhyperkalemia?2. Whatchangesshouldbemade
toachieveoptimalBP?
Question1
Whatarethepossiblecausesofhyperkalemia?a) Medsb) CKDc) Dietd) K+supplementse) Metabolicacidosisf) Alloftheabove
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Question1b
Whichofhermedicationscouldhaveledtohyperkalemia?a) Lisinoprilb) Labetalolc) Ibuprofend) Spironolactonee) Potassiumchloridef) a,d,andeg) Alloftheabove
Question2
WhatchangesshouldbemadetoachieveoptimalBP?a) Followinglowsodiumdietb) Medicationcompliancec) OTCmeds?d) DiscontinueHCTZ.e) Starttorsemidef) Startfurosemideg) Alloftheabove
Diuretics:Keytosuccess• LoopdiureticswheneGFR <30-50ml/min• DonotusethiazidediureticswheneGFR <30-50ml/min.Theydonotwork
with↓kidneyfunction• PlacebopillwithhighNaCl intake• Ifpatientsrequirepotassiumsupplementation=NOTcompliantwithlow
NaCl intake• Oncedailyloop• Torsemide morebioavailablethanfurosemide
Use50%doseoffurosemide.ParticularlywithmorealbuminuriaEx:Furosemide40mgBID =Torsemide 40mgdaily
• TreatsMANYcomplicationsofCKD1. Hyperkalemia2. Fluidoverload3. ElevatedBPs4. Metabolicacidosis5. UsageofACEi/ARBto↓albuminuria
Question3AfterdiscontinuingHCTZ,ibuprofenandpotassiumchlorideandinitiationoftorsemide 20mgQAM,repeatlabsreveal:• ↑inSCr 2.5to2.9mg/dl,BUN24,↓ineGFR from20to18ml/min,↓SK+5.5,↑CO222,↓UACR1500mg/g.
• BP145/80,P60,weight250lbs• Traceto+1LEedemaMeds:lisinopril 40mgBID,labetalol300mgTID,spironolactone12.5mgBIDandtorsemide 20mgQAM
Whatisyournextstep?
Question31. Decreaselisinopril to40mgdailydueto↑inSCr
and↓eGFR2. Decreasetorsemide to10mgdueto↑inSCr and
↓eGFR3. Increasetorsemide to30mgdailyto↓SK+,↑CO2,
↓LEedema,↓BPtogoalof<130/804. Discontinuespironolactoneandstartcalcium
channelblocker5. ReassessNaCl with24hrurinesodiumtoensure
<200mmol/24hrindicatinglowNaCl intake*RememberhighNaCl rendersRAASblockadeanddiureticslessefficacious=PLACEBOPILLS
ARS#1
WhichpatienthasaworseprognosisforCKDprogressiontoESRD?a) 75yoHTNeGFR 40ml/min,UACR150mg/gb) 22yoSLEeGFR 80ml/min,UACR3000mg/gc) 35yoADPKDeGFR 65ml/min,UACR100mg/gd) 55yoT2DMeGFR 50ml/min,UACR1500mg/
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ARS#2
45yoobese,T2DM,DLD,CAD,HTN,hyperuricemia,CKDpresentswithworseningofrenalfunction.SCr increasedto2.0mg/dl.eGFRdecreasedfrom58to42ml/min. UACR2000mg/g.A1C8.5%.Youwould_____andrefertoendocrinology.a) Continuemetformin1000mgBIDb) Decreasemetformin500mgBIDc) Discontinuemetformin
ARS#3
65yomalewithT2DM,uncontrolledHTNandCKDpresentswithBP175/60,P80,BMI35.Scr 2.4mg/dl,eGFR 32ml/min,K4.8mEq/LA1c9.8%,UACR2,550mg/gMeds:MetoprololXL50mgdaily,HCTZ25mgdailyandinsulin• Whatbloodpressuremedicationchangeswouldyou
initiallymaketoachieveoptimalBPgoalto<130/80?a) DiscontinueHCTZandstartfurosemideb) IncreasemetoprololbasedonHRc) StartACEIorARBd) Alloftheabove.Isthisatrickquestion?
Questions?
Thankyouforyourtime