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Chronic Kidney Disease (CKD) in the Hospitalized Patient Catherine Staffeld-Coit, MD.

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Presentation on theme: "Chronic Kidney Disease (CKD) in the Hospitalized Patient Catherine Staffeld-Coit, MD."— Presentation transcript:

1 Chronic Kidney Disease (CKD) in the Hospitalized Patient Catherine Staffeld-Coit, MD

2 No disclosures.

3 Objectives Explain the scope of CKD and its stages. Explain the scope of CKD and its stages. Discuss options for renal replacement therapy. Discuss options for renal replacement therapy. Review commonly seen problems in renal patients. Review commonly seen problems in renal patients. Explore the reasons for markedly higher incidence of cardiovascular disease in the renal population. Explore the reasons for markedly higher incidence of cardiovascular disease in the renal population.

4 Estimating Severity of CKD Can use many formulas. Can use many formulas. ALL require steady state, BUT not on dialysis. ALL require steady state, BUT not on dialysis. MDRD Calculator available @ many sites: MDRD Calculator available @ many sites:

5 Staging of CKD National Kidney Foundation

6 USRDS Projected Growth of Prevalent Dialysis and Transplant Populations U.S. Renal Data System, USRDS 2008 Annual Data Report, NIH, NIDDK, 2008

7 Geographic variations in adjusted incident rates of ESRD per million population, 2009, by HAS F ig 1.4 (Vol 2) Adj: age/gender/race; ref: 2005 ESRD patients. U.S. Renal Data System, USRDS 2011 Annual Data Report, NIH, NIDDK, 2011

8 Prevalent counts & adjusted rates of ESRD, by race Fig 1.12 (Vol 2) December 31 point prevalent ESRD patients. Adj: age/gender; ref: 2005 ESRD patients. U.S. Renal Data System, USRDS 2011 Annual Data Report, NIH, NIDDK, 2011

9 Prevalent Counts & adjusted rates of ESRD, by diagnosis Fig 1.14 (Volume 2) December 31 point prevalent ESRD patients. Adj: age/gender/race; ref: 2005 ESRD patients. U.S. Renal Data System, USRDS 2011 Annual Data Report, NIH, NIDDK, 2011

10 Causes of Renal Failure DM 30-40% DM 30-40% HTN 25-35% HTN 25-35% GN GN Genetic Genetic –Polycystic Kidney Disease –Alports Obstructive nephropathy Obstructive nephropathy Drug-induced Drug-induced Unknown Unknown U.S. Renal Data System, USRDS 2008 Annual Data Report, NIH, NIDDK, 2008

11 Adjusted all-cause mortality in the ESRD & general populations, by age, 2009 Fig 5.2 (Vol 2) Prevalent ESRD & general Medicare (non-ESRD) patients. Adj: gender/race; ref: Medicare patients, 2009. U.S. Renal Data System, USRDS 2011 Annual Data Report, NIH, NIDDK, 2011

12 FIGURE 17-15 Causes of death among U.S. transplant recipients with a functioning graft. CVD, cardiovascular disease. (From U.S. Renal Data System: USRDS 2005 Annual Data Report: Atlas of End- Stage Renal Disease in the United States. Bethesda, MD, National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, 2005, p 152.)

13 Overview of Dialysis Therapy Outpatient (in-center) Hemodialysis (HD) – usually done 3 times a week. Most common type. Outpatient (in-center) Hemodialysis (HD) – usually done 3 times a week. Most common type. Home therapies: Home therapies: –Daily or nocturnal HD. –Chronic Ambulatory Peritoneal Dialysis (CAPD) –Cyclic Peritoneal Dialysis usually performed at night. –Require patient or caregiver be thoroughly trained to perform independently. –Less common as in-center hemodialysis.

14 Renal Replacement Therapy NIDDK

15 Renal Transplantation Treatment, not cure. Treatment, not cure. Usually performed w/o nephrectomy. Usually performed w/o nephrectomy. Requires lifelong immunosuppression. Requires lifelong immunosuppression. Immunos may cause side effects (DM, HTN, hyperlipidemia, CVD, cancer, infection). Immunos may cause side effects (DM, HTN, hyperlipidemia, CVD, cancer, infection). NIDDK

16 Complications of Renal Failure (partial) Intradialytic Hypotension (during HD) Intradialytic Hypotension (during HD) Malnutrition Malnutrition GI Bleed GI Bleed Nephrogenic Systemic Fibrosis Nephrogenic Systemic Fibrosis Neurologic Neurologic Cardiovascular disease (CVD) Cardiovascular disease (CVD) Infection Infection Acquired Cystic Disease Acquired Cystic Disease Anemia Anemia

17 Hypotension Occurs in 20-30 % of HD treatments Causes: Rapid reduction of plasma osmolality causing extracellular water to shift into cells. Rapid reduction of plasma osmolality causing extracellular water to shift into cells. Rapid fluid removal/ultrafiltration (UF) of>1.5 L/hr. Rapid fluid removal/ultrafiltration (UF) of>1.5 L/hr. Poor cardiac reserve. Poor cardiac reserve. Autonomic neuropathy. Autonomic neuropathy. BP meds. BP meds. Eating before or during dialysis. Eating before or during dialysis. May present 1-2 hours post-treatment. May present 1-2 hours post-treatment. Therapies- Volume replacement, adjust meds, UF slowly, check EF.

18 Hypertension Seen in 85% of renal patients. Seen in 85% of renal patients. Salt/water excess usual cause. Salt/water excess usual cause. Elevated renin secretion from diseased kidneys is common. Elevated renin secretion from diseased kidneys is common.

19 Hypertension ESA side effect ESA side effect Sympathetic over activity. Sympathetic over activity. Non-compliance with meds or withholding prior to dialysis. Non-compliance with meds or withholding prior to dialysis. Salt and water restriction not followed. Salt and water restriction not followed.

20 Malnutrition Associated with decreased survival Causes: Drug effects. Drug effects. Chronic constipation. Chronic constipation. Lack of understanding of renal nutrition. Lack of understanding of renal nutrition. Low income. Low income. Malabsorption and GI motility disorders. Malabsorption and GI motility disorders. Impaired taste. Impaired taste. All Patients are evaluated and followed by dietician in dialysis unit. CKD patients should receive dietary education as part of CKD care.

21 GI Bleed Dont assume anemia is simply from CKD. Check iron levels and w/u when deficient. Dont assume anemia is simply from CKD. Check iron levels and w/u when deficient. Gastritis - most common. Gastritis - most common. Angiodysplasia - second most common. Angiodysplasia - second most common. Uremic platelet dysfunction contributes to the severity- DDAVP can help short-term. Uremic platelet dysfunction contributes to the severity- DDAVP can help short-term. If patient is possible transplant candidate, use WBC filter with PRBC transfusions when blood products needed… decreases HLA antibody formation. If patient is possible transplant candidate, use WBC filter with PRBC transfusions when blood products needed… decreases HLA antibody formation.

22 Nephrogenic Systemic Fibrosis Typically starts with patients reporting swelling and a tight feeling in extremities. Typically starts with patients reporting swelling and a tight feeling in extremities. Skin changes may be red or dark patches, papules, plaques, or nodules. Skin changes may be red or dark patches, papules, plaques, or nodules. Progressing over days to weeks to inhibit flexion and contraction of joints & contractures. Progressing over days to weeks to inhibit flexion and contraction of joints & contractures. Skin becomes woody with peu dorange consistency Skin becomes woody with peu dorange consistency Lesions often symmetrical, involving LE first, then UE. Lesions often symmetrical, involving LE first, then UE. Most common with GFR < 30 and Gadolinium exposure. Most common with GFR < 30 and Gadolinium exposure. From Cowper NFD/NSF Website.

23 Nephrogenic Systemic Fibrosis Soft tissue swelling & contractures Raised and erythematous nodular plaques, & linear and confluent regions of fibrosis From nephrogenic-systemic-fibrosis.info

24 Neurologic Complications of Uremia Uremic neuropathy is the most common neurologic finding. Uremic neuropathy is the most common neurologic finding. Uremic encephalopathy (UE) develops when GFR < 10% of normal. Uremic encephalopathy (UE) develops when GFR < 10% of normal. –Rare in well dialyzed patients. –Seizures are seen in 25% of patients with UE. Restless legs syndrome is reported in > 40% of uremic patients. Restless legs syndrome is reported in > 40% of uremic patients. Myopathy, optic neuropathy and mononeuropathies noted. Myopathy, optic neuropathy and mononeuropathies noted. Hyperkalemia can cause flaccid quadriparesis. Hyperkalemia can cause flaccid quadriparesis. Goetz: Textbook of Clinical Neurology, 3rd ed

25 Neurologic Complications of Uremia (cont.) Vestibulocochlear and neuromuscular junction disturbances can be seen in association with aminoglycoside atb. Vestibulocochlear and neuromuscular junction disturbances can be seen in association with aminoglycoside atb. Loop diuretics can cause tinnitus. Loop diuretics can cause tinnitus. Amyloid fibrils ( 2 microglobulin deposits) can cause carpal tunnel syndrome. Amyloid fibrils ( 2 microglobulin deposits) can cause carpal tunnel syndrome. Goetz: Textbook of Clinical Neurology, 3rd ed

26 Neurologic Complications of Uremia (cont.) Subdural hemorrhage. Subdural hemorrhage. Dialysis headaches. Dialysis headaches. Exacerbation of migraine headaches. Exacerbation of migraine headaches. Ischemic monomelic neuropathy. Ischemic monomelic neuropathy. Goetz: Textbook of Clinical Neurology, 3rd ed

27 Neurologic Complications of Uremia (cont.) Dysequilibrium Syndrome Dysequilibrium Syndrome –Cerebral edema d/t rapid reduction of omolality during hemodialysis. Dialysis dementia (vascular, 2- macroglobulin). Dialysis dementia (vascular, 2- macroglobulin). Goetz: Textbook of Clinical Neurology, 3rd ed

28 Neurologic Complications of Uremia (cont.) Vitamin deficiency Vitamin deficiency –Water soluble vitamins dialyzed out. –Poor nutrition common. –Nephrology vitamins available. Goetz: Textbook of Clinical Neurology, 3rd ed

29 Neurologic Complications of Uremia (cont.) Phenytoin has decreased plasma binding and higher free (active) drug. Phenytoin has decreased plasma binding and higher free (active) drug. –Check free phenytoin level. –Usually the same loading and maintenance dosed used. –Since half-life decreased, TID dosing regimen is favored over BID. Goetz: Textbook of Clinical Neurology, 3rd ed

30 Syncope in Renal Disease Arrhythmias Arrhythmias –Intrinsic –Electrolyte induced (K, Calcium, Mg.) –Acidemia, or rarely alkalemia. Intra- or post-dialytic hypotension. Intra- or post-dialytic hypotension. Common causes occur commonly. Common causes occur commonly. –Given CVD risk, need thorough evaluation for vascular disease. Barbour et al. Semin Nephrol 2001; 21 (1) : 66-78.

31 CVD and CKD Primary cause of death is accelerated CVD Primary cause of death is accelerated CVD AHA: ESRD should be considered highest risk. 1 Considered a CV risk equivalent. AHA: ESRD should be considered highest risk. 1 Considered a CV risk equivalent. Entire spectrum of CKD associated with increased risk. 2-4 Entire spectrum of CKD associated with increased risk. 2-4 –Very high prevalence of traditional CKD risks. –HTN & cholesterol have U-shaped relationship. 1. Sarnak et al. Circulation 2003; 108: 2154-2169. 2. Collins et al. Kidney Int suppl 2003. S24-S31. 3. Henry et al. Kidney Int 2002; 62:1402-1407. 4. Muntner et al. J Am Soc Nephrol 2002; 13:745-753

32 Dyslipidemia Lipids combine with apolipoproteins to form lipoproteins. Lipids combine with apolipoproteins to form lipoproteins. Lipoprotein profiles are affected by CKD Lipoprotein profiles are affected by CKD –HDL, LDL and total cholesterol decline with worsening renal function. 1 –Dense LDL and lipoprotein (a) are increased. 2 –Elevated lipoprotein(a) is an independent risk factor for CVD in hemodialysis patients and is associated with vascular events. 3 1.Kanske BL. Am. J Kidney Dis, 1988; 32 (suppl 3) : S142-56. 2.Kwan et al. J. Am. Soc Nephrol 2007; 18 (4) : 1246-61. 3.Cressman et al. Circulation 1992; 86 (2) : 475-82.

33 CV Mortality Foley et al. Am J Kidney Dis 32 (suppl):S112–S115, 1998 Brenner and Rector's The Kidney, 8th ed.

34 CVD in patients with or without CKD, 2009 fig 4.1 (Vol 1) December 31 point prevalent Medicare enrollees age 66 & older, with fee-for-service coverage for all of 2009. U.S. Renal Data System, USRDS 2011 Annual Data Report, NIH, NIDDK, 2011

35 Effects of CKD on Cardiovascular System McCullough PA: Why is chronic kidney disease the spoiler for cardiovascular outcomes? J Am Coll Cardiol 41;725, 2003

36 Non-Traditional CVD Risk Factors in Renal Disease Albuminuria Albuminuria Malnutrition Malnutrition Hyperhomocysteinemia Hyperhomocysteinemia Elevated Lp(a) Elevated Lp(a) Low GFR Low GFR Anemia Anemia Inflammation Inflammation ECF overload ECF overload Endothelial dysfunction Endothelial dysfunction Metabolic syndrome Metabolic syndrome Abnormal Ca/PO4 metabolism Abnormal Ca/PO4 metabolism Hyperparathyroidism Hyperparathyroidism

37 Dyslipidemia (cont.) Triglycerides tend to increase with CKD, especially NS and those on dialysis. 1 Triglycerides tend to increase with CKD, especially NS and those on dialysis. 1 NFK recommends lifestyle modifications for those with CKD. NFK recommends lifestyle modifications for those with CKD. Target LDLC is < 100 mg/dl for all renal patients. Target LDLC is < 100 mg/dl for all renal patients. 1. Kwan et al. J. Am. Soc Nephrol 2007; 18 (4) : 1246-61.

38 Dyspnea in ESRD Pulmonary edema, often non-cardiogenic. Pulmonary edema, often non-cardiogenic. –Failure to decrease est dry weight (EDW) in those losing weight. –Excess intake, exceeding capacity for UF. –Peritoneal dialysate leakage. High output cardiac failure can develop from AV grafts or fistulae which can have blood flow of >20-30% of cardiac output. High output cardiac failure can develop from AV grafts or fistulae which can have blood flow of >20-30% of cardiac output. Pneumothorax or hemothorax after catheter placement. Pneumothorax or hemothorax after catheter placement. Pericardial effusion or cardiac tamponade. Pericardial effusion or cardiac tamponade.

39 Initial Rx of Pulmonary Edema in Renal Failure Supplemental oxygen. Supplemental oxygen. Morphine. Morphine. High dose loop Diuretic (if significant residual UO). High dose loop Diuretic (if significant residual UO). –May work as vasodilator. Preload reduction with nitrates. Preload reduction with nitrates. Rx of HTN. Rx of HTN. Definitive rx is fluid & salt removal with dialysis- not always urgent. Definitive rx is fluid & salt removal with dialysis- not always urgent.

40 Chest Pain in CKD 50% of renal deaths are related to ischemic heart disease, so ACS has to be in Ddx. 50% of renal deaths are related to ischemic heart disease, so ACS has to be in Ddx. Baseline EKG often abnormal d/t LVH, e-lyte disturbances or fluid overload. Baseline EKG often abnormal d/t LVH, e-lyte disturbances or fluid overload. ST segment elevation is indicative of ACS. 1 ST segment elevation is indicative of ACS. 1 Chronic troponin elevations are misleading. Chronic troponin elevations are misleading. Uremic Pericarditis Uremic Pericarditis Pulmonary embolus, 12.5% incidence in ESRD vs 22% in general population. 2 Pulmonary embolus, 12.5% incidence in ESRD vs 22% in general population. 2 1.Goldsmith et al, Kidney Int 2001; 60 : 2059-78. 2.Wiesholder et al, Am J Kidney Dis 1999; 33:702-8.

41 Chest Pain in Renal Disease (cont) Higher prevalence of silent ischemia. Higher prevalence of silent ischemia. Patient with CKD presenting with chest discomfort has 40% cardiac event rate @ 30 days. 1 Patient with CKD presenting with chest discomfort has 40% cardiac event rate @ 30 days. 1 ESRD patients have highest mortality after AMI. 2 ESRD patients have highest mortality after AMI. 2 1.McCullough et al: Arch Intern Med 2002; 162:2464. 2.Braumwald

42 Approach to ESRD patient with Suspicion of CAD McCullough PA: Kidney Int Suppl 95:s51-58, 2005

43 Long-term survival by CAD management strategy in patients with CKD or ESRD. Keely et al. Am J Cardiol 92:509-514, 2003

44 Management of CVD in Renal Failure Lifestyle modification, as per general population. Lifestyle modification, as per general population. –Including physical activity when possible. Control BP. Control BP. Goal LDL < 100. JNC7 recognizes CKD as independent risk factor Goal LDL < 100. JNC7 recognizes CKD as independent risk factor Have low threshold to evaluate atypical findings: Have low threshold to evaluate atypical findings: –Worsening fatigue. –Hypotension in someone with hx HTN. –Atypical chest discomfort. –Dyspnea not related to pulmonary edema.

45 Calcification & vasculature Calcifications of the pelvic arteries. London GM, et al. Arterial media calcification in end-stage renal disease: impact on all-cause and cardiovascular mortality. Nephrol Dial Transplant. 2003;18(9):1731-1740, by permission of Oxford University Press.

46 Infections and Renal Disease Renal failure = immunocompromised state. Renal failure = immunocompromised state. Hypothermia common in renal failure. Hypothermia common in renal failure. –Fever often absent. –Low grade temps can indicate serious infection. Catheters and grafts are often source. Catheters and grafts are often source. Higher incidence of HCV. Higher incidence of HCV. Note many antibiotics are dialyzable and require dose adjustment. Note many antibiotics are dialyzable and require dose adjustment.

47 Fatal Bacterial Infections in HD & PD in Australia and New Zealand 1995-2005 Johnson et al. AM J Kidney Dis 53:290-297.

48 Acquired Renal Cystic Disease (ARCD) Renal neoplasms seen in 10% of chronic HD patients. Adenomas most common. Renal neoplasms seen in 10% of chronic HD patients. Adenomas most common. With ARCD, prevalent incidence is 20-25%. With ARCD, prevalent incidence is 20-25%. Present silently or w flank pain and hematuria. Present silently or w flank pain and hematuria. RCC has 3-7X higher incidence in ESRD than general population. RCC has 3-7X higher incidence in ESRD than general population. ARCD may regress post-tx. ARCD may regress post-tx. Wein: Campbell-Walsh Urology, 9th ed.

49 Acquired Renal Cystic Disease (ARCD) Wein: Campbell-Walsh Urology, 9th ed.

50 Secondary Hyper- parathyroidism (SPTH) CKD is the most common cause of SPTH. CKD is the most common cause of SPTH. –Failing kidneys do not convert enough vitD to its active form. –Failing kidneys inadequately excrete phosphorus. This results in (insoluble) ca-phos complexes that remove calcium from the circulation. Both processes leads to hypocalcemia & secondary hyperparathyroidism. Both processes leads to hypocalcemia & secondary hyperparathyroidism. Vascular calcification common. Vascular calcification common.

51 Rx Secondary Hyperparathyroidism Low phos diet and phos binders. Low phos diet and phos binders. Active Vit D supplements calcitriol (Rocaltrol), doxercalciferol (Hectorol), paricalcitol (Zemplar) Active Vit D supplements calcitriol (Rocaltrol), doxercalciferol (Hectorol), paricalcitol (Zemplar) Calcimimetic- cinacalcet (Sensipar) mimics the action of calcium on tissues by allosteric activation of ca-sensing receptor. Calcimimetic- cinacalcet (Sensipar) mimics the action of calcium on tissues by allosteric activation of ca-sensing receptor. Educate and reinforce, re-educate. Educate and reinforce, re-educate.

52 Summary Renal failure is a systemic disease that affects every other organ system. Renal failure is a systemic disease that affects every other organ system. For any age, CKD and ESRD patients have markedly increased mortality compared to general population. For any age, CKD and ESRD patients have markedly increased mortality compared to general population. CVD has very high incidence and needs to be looked for and treated aggressively. CVD has very high incidence and needs to be looked for and treated aggressively. Vague presentations of infection or CVD are common. Vague presentations of infection or CVD are common.

53 Questions? cstaffeld@ochsner.org


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