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Kidney Disease Workup – When to refer to Nephrologist Family Practice Review Feb 2013 4:30-5:30 Jeff Kaufhold MD, FACP Master Physician, Ohio University.

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Presentation on theme: "Kidney Disease Workup – When to refer to Nephrologist Family Practice Review Feb 2013 4:30-5:30 Jeff Kaufhold MD, FACP Master Physician, Ohio University."— Presentation transcript:

1 Kidney Disease Workup – When to refer to Nephrologist Family Practice Review Feb :30-5:30 Jeff Kaufhold MD, FACP Master Physician, Ohio University Heritage School of Medicine Nephrology Associates of Dayton

2 Renal Review Now Kidney Disease- Work-up & When to Refer to a Nephrologist - What Drugs Not to Prescribe and What Drugs Work for Hypertension Mark D. Oxman, D.O. 5:30 p.m. - 6:30 p.m. Cloudy with Occasional Chance of Crystals: What You Can Learn from the Urine (Clinical Significance & Billing Codes and Reimbursment) Mark D. Oxman, D.O.

3 Pre Test Which Treatment has the LEAST impact on progression of renal disease? A. Use of ACE inhibitors B. Referral to a nephrologist C. Use of DHP calcium Channel Blocker D. Control of Diabetes to A1c < 8.0 E. The nature of the underlying renal Disease

4 New Terminology ARF - RIFLE criteria 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

5 CKD prevalence in world Populations CountryPopulationCKD est. China India Indonesia Pakistan Philipines Vietnam Assumes 2.72 % incidence

6 CKD Stages Stage 1. Normal function with known dz Stage 2. GFR Stage 3. GFR Stage 4. GFR Stage 5. GFR less than 15. Stage 6. ESRD on dialysis.

7 US Population with CKD Coresh, Selvin, Stevens. Prevalence of CKD in the US. JAMA.2007;298(17)2038.

8 Approach as CKD progresses ----Stage 3--- Stage 4 Stage 5 GFR

9 Preparation of the Patient Manage CRF Stages 1, 2, 3. Control BP Preferentially with ACE Control Diabetes with Target A1c < 8, based on the DCCT, ideally < 6.5 Careful with drug dosing Prevent Hyper PTH Vit D Calcium acetate Phosphate binder Diet Education

10 Preparation of the Patient Stage 4 and 5 Manage Fluids Dialysis education Access Placement Prevent anemia Prevent Malnutrition Start ACE? metolazone NKF program AV fistula, PD cath Epogen, Iron This can get tricky Stop ACE?

11 Medical treatment in CKD Which drugs To avoid, and Which drugs Work for HTN

12 What Drugs to Avoid Drugs to avoid when GFR is less than 40: NSAIDs Bactrim IV Contrast Fleets Enemas Metformin, Xarelto For GFR less than 30, need to be careful with combinations of drugs like ACE and Spironolactone.

13 Which Drugs work for HTN? Global treatment of HTN Use of Common Medications in CKD Steps to improve survival in CKD Nephrologists approach to Hypertension Treatment.

14 Natl Health & Nutrition Exam Survey NHANES Control of Hypertension JNC 7 Dec 2003

15 Medicare Part D & MarketScan CKD patients with at least one claim for an ACEI/ARB/renin inhibitor in the 12 months following the disease-defining entry period, by CKD diagnosis code, 2008 Figure 2.14 (Volume 1) Point prevalent Medicare CKD patients age 65 & older & MarketScan CKD patients age 50–64.

16 Medicare Part D & MarketScan CKD patients with at least one claim for a beta blocker in the 12 months following the disease-defining entry period, by CKD diagnosis code, 2008 Figure 2.15 (Volume 1) Point prevalent Medicare CKD patients age 65 & older & MarketScan CKD patients age 50–64.

17 Medicare Part D & MarketScan CKD patients with at least one claim for a DHP calcium channel blocker in the 12 months following the disease-defining entry period, by CKD diagnosis code, 2009 Figure 2.16 (Volume 1) Point prevalent Medicare CKD patients age 65 & older & MarketScan CKD patients age 50–64.

18 Prevalence of comorbidity in NHANES 2001–2008 participants, by risk factor, expanded eGFR categories, & method used to estimate GFR Figure 1.5 (Volume 1) NHANES 2001–2008 participants age 20 & older. Note how HTN is bigger problem as GFR falls

19 Medicare Part D & MarketScan CKD patients with at least one claim for a lipid lowering agent in the 12 months following the disease-defining entry period, by CKD diagnosis code, 2008 Figure 2.17 (Volume 1) Point prevalent Medicare CKD patients age 65 & older & MarketScan CKD patients age 50–64.

20 Mortality rates in NHANES participants, by eGFR: MDRD equation Figure 1.11 (Volume 1) NHANES 1999– 2004 participants age 20 & older.

21 Cumulative probability of a physician visit in the year following CKD diagnosis by physician specialty & dataset Figure 2.10 (Volume 1) Patients alive and eligible all of 2008, CKD diagnosis represents date of first CKD claim during 2008, physician claims searched during 12months following that date. Only about 30 %

22 How to improve CV Morbidity in CKD? 1. Early referral to Nephrology 2. Consider a patient with CKD 4, 5, and ESRD as having the same risk as a patient who HAS ALREADY HAD THEIRFIRST HEART ATTACK. Beta Blocker Aspirin Statin restart ACE inhibitor or ARB once pt on dialysis To prevent a vessel wall thrombus

23 Hall Thrombus

24 Hypertension Case Presentation 56 y.o. A.A. male prior weight lifter presents for refractory HTN. Normal labs and UA. Normal CXR and EKG. Meds:Clonidine 0.2 BID ACE inhibitor Diltiazem 300 mg daily

25 Case Presentation Physical Exam: BP 170 / 110 Pulse 85 Edema 2 +

26 Case Presentation Special populations help define your approach. African Americans: CHF Diabetics:

27 Case Presentation Special populations help define your approach. African Americans: Volume Mediated, Low renin low Aldo. May respond better to diuretics. CHF:ACE, Diuretics, B-blocker, ASA Diabetics:ACE or ARB.

28 Case Presentation 56 y.o. A.A. male with edema, HTN Normal labs and UA. Normal CXR and EKG. Meds:Clonidine 0.2 BID ACE inhibitor Diltiazem 300 mg daily Whats Missing???

29 Case Presentation 56 y.o. A.A. male with refractory HTN. Meds:Clonidine 0.2 BID ACE inhibitor - Stopped Diltiazem 300 mg daily I added HCTZ 50 mg daily.

30 Case Presentation 56 y.o. A.A. male with refractory HTN. Meds:Clonidine 0.2 BID Diltiazem 300 mg daily HCTZ 50 mg daily. Still swelling, BP a little better. 156 / 100.

31 Case 56 y.o. AA male with refractory HTN. I changed diuretics to Lasix and ultimately added Zaroxolyn. I get a call 3 days later: Swellings gone, but I cant get out of bed – too dizzy! He had lost 15 lbs.

32 Case Presentation 56 y.o. A.A. male with refractory HTN. Meds:Lasix 40 mg BID Zaroxolyn 5 mg weekly No swelling, BP 126 / 80. Pt reports joint pain and swelling. What test do you order next?

33 Case Uric acid level is 12 Creatinine 1.4 K 3.8 Glucose 244 (nonfasting)

34 Case Started Allopurinol for gout. Pt started exercising and watching diet. Sugars normalized without treatment.

35 Joint National Commission JNC 11980founded on HDFP JNC 21984Intro of ACE, alpha B. JNC 31986Special situations JNC 41988Many agents 1 st line JNC 51993Back to stepped care. JNC 61997ACE for Diabetics JNC

36 HYPERTENSION JNC VII Outline l Epidemiology of HTN l Evaluation of HTN l NON Pharmacologic treatments: Wt loss, diet, exercise, alcohol l Drug treatment l Special Issues in HTN

37 HYPERTENSION JNC V l "Because diuretics and B-Blockers are the only classes of drugs that have been used in long-term controlled trials and shown to reduce morbidity and mortality, they are recommended as first- choice agents unless they are contraindicated or unacceptable, or unless there are special indications for other agents."

38 Stages of Hypertension Normal Prehypertension Stage 1 Stage 2 < 120 / / / > 160 / >100

39 Treatment of Hypertension Stage 1 or Single agent – HCTZ for most pts. B- Blocker for females/ high heart rate. Stage 2 I start with DHP CCB (Nifedipine XL) plus one or both of above. Resistant HTN I look for CLASSES of agents

40 Classes of Antihypertensives Diuretics Rate control agentsBBlocker, Verapamil, Diltiazem ACE/ ARBs Vasodilators Dihydropyridines, Hydralazine, Alpha blockers, Minoxidil Central agents: clonidine, aldomet.

41 Nephrology level htn I tell the pt that well need to control the main route plus the main detours causing the HTN. Average of 3.1 medications to achieve control Rate control (pulse < 78) Diuretic Vasodilator DHP CCB, Hydralazine, Cardura, Minoxidil. ACE / ARB (accept 30% increase in creat if BP responds)

42 Refer to Nephrologist If unable to control on 3 drug regimen which includes Rate control, diuretic. If you are considering Minoxidil or renal angio. If creatinine climbs more than 30 % or if creatinine is over 2.0.

43 Post Test Which Treatment has the LEAST impact on progression of renal disease? A. Use of ACE inhibitors B. Referral to a nephrologist C. Use of DHP calcium Channel Blocker D. Control of Diabetes to A1c < 8.0 E. The nature of the underlying renal Disease

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