Presentation on theme: "Managing Kidney Disease in the Homeless Population E. Jennifer Weil, MD Phoenix Epidemiology and Clinical Research Branch."— Presentation transcript:
Managing Kidney Disease in the Homeless Population E. Jennifer Weil, MD Phoenix Epidemiology and Clinical Research Branch
in memory of Larry Coleman, my patient 10/18/99 – 4/31/04 Rest in Peace Temple University, Philadelphia, PA
What Kidneys Do Kidneys control the amount of water and other chemicals in blood. Kidneys remove harmful substances Kidneys control blood pressure Kidneys help make red blood cells Kidneys promote strong bones
Chronic Kidney Disease Chronic kidney disease (CKD) is the permanent loss of kidney function in both kidneys as a result of Physical injury or A disease that damages both kidneys, such as DIABETES Damaged kidneys do not remove wastes do not remove extra water from the blood as well as they should.
What Else About CKD? CKD is a familial disease. Risk for CKD increases if a blood relative has kidney failure. CKD is a silent condition. In the early stages, there are no symptoms. CKD develops so slowly that people don't realize they're sick until the disease is advanced and they are rushed to the hospital for life-saving dialysis.
Kidney Failure is Increasing in the US
Incident Counts & Adjusted Rates, by Race Incident ESRD patients; rates adjusted for age & gender.
lla illi lla illi Incident Counts and Rates of ESRD by Primary Diagnosis USRDS 2006
Kidney Disease Has 5 Stages StageDescriptionSymptoms 1Slightly damaged NONE! 2Cleaning reduced NONE! 3Halfway to failure NONE! 4On the edge of failing Could have swelling, nausea 5KIDNEY FAILURE – starting DIALYSIS Could have swelling, nausea, shortness of breath. Need blood test to know for sure.
A Familiar Filter
Pretend this Filter is in Kidneys.. BLOOD ALBUMIN URINE
A Familiar Filter is Damaged
Damaged Kidney Filters microalbuminuria = micro (small) albumin (protein) uria (urine) BLOOD ALBUMIN URINE
Failing Kidney Filters SCARS
blood is clean (red) urine removes waste (yellow) NORMAL plenty of urine
blood is clean (red) urine removes waste (yellow) plenty of urine albumin or red blood cells STAGES 1 & 2 GFR > 59
kidneys don’t clean blood as well urine removes less waste less urine albumin or red blood cells STAGE 3 GFR scar
kidneys don’t clean blood as well urine removes less waste less urine albumin or red blood cells STAGE 4 GFR scars bigger
kidneys don’t clean blood urine removes less waste very little urine albumin or red blood cells STAGE 5 GFR < 15 scars replace most of kidneys too much fluid in heart
Kidney Disease Has 5 Stages StageDescription eGFR 1Slightly damaged ≥ 90 ml/min 2Cleaning reduced ml/min 3Halfway to failure30 – 59 ml/min 4On the edge of failing15 – 29 ml/min 5KIDNEY FAILURE – starting DIALYSIS < 15 ml/min
Stages 1 & 2 Normal eGFR ≥ 60 ml/m Kidney damage for more than 3 months as manifested by Abnormalities in the tissue of the kidney (biopsy) or Markers of kidney damage including Abnormalities in the composition of urine or Changes seen by radiological images (x-ray, CT scan, ultrasound etc.) Risks associated Progression Heart disease
How to Stage Calculate eGFR with age, sex, race, and creatinine Find out if there are changes in kidneys for more than 3 months: Urinalysis positive for protein or blood OR Urine albumin to creatinine ratio (AKA: microalbumin, ACR): > 30 mg/g OR Ultrasound or other imaging test is abnormal Look at the table
Kidney Disease Has 5 Stages StageDescription eGFR 1Slightly damaged MUST HAVE SIGNS OF DAMAGE ≥ 90 ml/min 2Damaged and cleaning reduced MUST HAVE SIGNS OF DAMAGE ml/min 3Halfway to failure30 – 59 ml/min 4On the edge of failing15 – 29 ml/min 5KIDNEY FAILURE – starting DIALYSIS < 15 ml/min
Quiyo, Tessie Urine creat 60.6 mg/dL Urine albumin25.9mg/dL Microalbumin, random426.9mg/g Serum creat0.9 mg/dL Est GFR> 60ml/m How to stage: presence of macroalbuminuria means there is kidney disease present. eGFR > 60 means Stage 1 or Stage 2. Our methods do not allow distinction between Stages 1 and 2.
Joe, Lalo Urine creat 85.2 mg/dL Urine albumin2.4 mg/dL Microalbumin, Random28mg/g Serum creat2.2 mg/dL Est GFR34ml/m How to stage: no albuminuria but eGFR = 34 ml/m, Stage 3.
Cachora, Dale Urine creat 60.0 mg/dL Urine albumin31.5mg/dL Microalbumin, Random524.5mg/g Serum creat2.8 mg/dL Est GFR25ml/m How to stage: presence of macroalbuminuria means there is kidney disease present. eGFR 25 means Stage 4.
Cachora, Dale UrinalysisBlood 3+ Protein 2+ Serum creat1.4 mg/dL Est GFR50ml/m How to stage: presence of blood and protein means there is kidney disease present. eGFR 50 means Stage 3.
Cachora, Dale Renal ultrasoundSingle kidney Serum creat1.1 mg/dL Est GFR≥ 60ml/m How to stage: single kidney is abnormal, and eGFR ≥ 60 means Stage 1 or 2.
Columbus Neighborhood Health Center Study, 2005 People with Diabetes or Hypertension
Etiology of CKD Hypertension Diabetes Other Bilateral renal artery stenosis (heart disease, stroke patient) Kidney obstruction (stones, prostate, cancer patient) Interstitial nephritis (lithium, NSAIDs) Glomerulonephritis (heroin, HIV, hepatitis C, hepatitis B patients) Congenital kidney disease (polycystic, Alport’s etc.) Multiple myeloma (older patient, anemia) Lupus (lots of other manifestations in joints, skin, brain)
Complete Work-Up for Etiology of CKD Diabetes: duration, A1C, dilated retinal exam, sensory testing with monofilament Hypertension: duration, number of meds Other diseases Lupus: ANA, C3, C4 Vasculitis: ANCA, Anti-GBM, cryoglobulins Multiple Myeloma: SPEP with IFE, UPEP with IFE Infectious Diseases: HBSAg, HCV, HIV screens Renal Ultrasound for obstruction, small kidneys or anything else
Core Labs for All Follow-Up CBC: more frequently in advanced stages Chem 7: more frequently in advanced stages Urinalysis: helpful for diagnosis, helpful for UTI Urine microalbuminuria: helpful at diagnosis and to see if ACE inhibitor or ARB is working Lipid panel: check while adjusting lipid meds HbA1C: if diabetic – every three months Blood pressure – every visit
When to slow CKD down? StageDescriptionSymptoms 1Slightly damaged NONE! 2Cleaning reduced NONE! 3Halfway to failure NONE! 4On the edge of failing Could have swelling, nausea 5KIDNEY FAILURE – starting DIALYSIS Could have swelling, nausea, shortness of breath. Need blood test to know for sure.
How to Slow CKD Educate patients on how they can control many of the things that can make CKD worse and may lead to kidney failure. Gain tight control of blood glucose to delay or prevent kidney failure, where appropriate. Keep blood pressure below 130/80 mm Hg. A combination of two or more drugs may be necessary ACE (angiotensin-converting enzyme) inhibitors and ARBs (angiotensin receptor blockers) protect the kidneys better than other blood pressure medicines. Dietary therapy when practicable, low protein, low sodium, and later low potassium and low phosphorus.
Renoprotective Drugs ACE inhibitors Lisinopril (longest half-life) Captopril ARBs Telmisartan (longest half-life) Candesartan Dosage: maximal tolerated by blood pressure, serum creatinine and potassium Combination of ACE inhibitor and ARB: almost always unnecessary (but combination with other anti-hypertensive drugs to be expected) Contraindicated: women of childbearing potential, allergic patients Enalapril Ramipril Valsartan Losartan Fosinopril (hepatic) others Irbesartan others
Heart Disease in CKD Modification of risk Lipid control Smoking cessation Diabetes control Blood pressure control Lower albumin or protein in urine Medicines Statins, other lipid agents Anti-hypertensive drugs, especially ACE, ARB, beta- blocker Aspirin Lifestyle: diet and exercise
Behavioral Changes that Affect CKD Outcomes Ask to get tested for kidney disease Ask questions about kidney disease Take medicines regularly Stop smoking Stop using illicit drugs Abstain from alcohol Lose weight if overweight or obese Exercise if sedentary Adjust diet Keep appointments with health care system
Adapting Practice for Homeless Diagnostic testing for diseases other than hypertension, diabetes Expensive Difficult to do Set criteria: evaluate for all? Transmissable? Easy tests? Diabetes (standard goal is A1C ≤ 7%) Check appropriateness of A1C target Hypoglycemia is dangerous Hypertension (standard goal ≤ 130/80 mmHg) Avoid ACE inhibitors and ARBs in women of childbearing potential Easier to get to goal, fewer risks than A1C, great results Dietary management Difficult to control what / when patients eat Follow-up labs Not so expensive
Complications of CKD renal osteodystrophy Stage 3 Anemia: CBC, iron Metabolic bone disease: intact Pth, phosphorus, vitamin D, calcium Stage 4 Anemia: as above Metabolic bone disease: as above Hyperkalemia: serum potassium Volume overload: edema, pulmonary edema Acidosis: bicarbonate, arterial blood gas Stage 5 All of the above Uremia (nausea, vomiting, malnutrition, weight loss, pericarditis, confusion, myoclonus, seizures): BUN and creatinine
When to Refer KDOQI Guidelines: Stage 3 Nephrotic syndrome Uncontrolled hypertension NOT IDEAL (BUT IT HAPPENS) When dialysis is necessary
Preparation for Dialysis Modality choice Peritoneal Dialysis Hemodialysis Access Fistula first Catheter Graft Hepatitis immunization Vitamins Identification of dialysis unit
Dialysis Lifestyle Treatment 3 x per week 4 hours +/- per treatment Transportation for treatment Medications: average of 9 Diet Low sodium, low potassium, low phosphorus, high protein diet Fluid restriction
Resources for Homeless Dialysis Patients Medicare ESRD Program (Federal) Covers cost of dialysis treatment Does not cover food or shelter Medicaid (Federal, administered by states) Each state has various rules cover cost of medication, for example Does not cover food or shelter Can cover disability, if patient meets criteria Eligibility for programs: patients with no work history do not qualify.
Healthcare Resources Alameda County, CA, 2000
Dialysis Team Physician Nurse Technician Dietician Social Worker Patient and family
Case of Larry Coleman 55 year old African-American gentleman Hypertension, untreated, then kidney failure At time he started dialysis Living out of his car No stable food supply Functionally illiterate Using drugs At the time I met him, “disabled” Living in an apartment Stable food supply and medicines paid for Still functionally illiterate Still using drugs, but much less and with good effect A great friend and an advocate for his fellow patients