1. SLOW- COOKING THE BEANS “OR, HOW TO STOP WORRYING AND APPLY SOME LOVE TO THE KIDNEYS” AN APPROACH TO CKD SARA KATE LEVIN, MD JANUARY 2014

2. OBJECTIVES  Understand when may be appropriate to screen for Kidney Disease  Understand the difference between Chronic and Acute Kidney Failure  Gain a basic approach to initial evaluation of suspected CKD  Understand how to manage and when to refer based on CKD stage

3. CASES Case#1 63 yo Woman with 25 yr hx of HTN, 15 yr hx of DM2 out of care for 10 years – here to re-establish care Case #2 38 yo African-American man with hx of poorly controlled htn since his early 20s with avg BPs 150-170/80-100 Case #3 28 yo G1P0 13 weeks gestation evaluated in initial prenatal visit to have BP 168/96 and 3+ protein in her urine

4. DISTRIBUTION OF POINT PREVALENT GENERAL MEDICARE (AGE 65 & OLDER) & MARKETSCAN (AGE 50–64) PATIENTS WITH CODED DIABETES, CKD, CHF, & CVA, 2010 Point prevalent general (fee-for-service) Medicare patients age 65 & older; point prevalent MarketScan patients age 50–64. Diabetes, CKD, CHF, & CVA determined from claims.

5. LIFE EXPECTANCY OF NHANES PARTICIPANTS WITH OR WITHOUT CKD, 1999–2004 NHANES participants, 1999–2004; eGFR calculated using CKD-EPI equation; urine albumin creatinine ratio (ACR).

6. ODDS RATIO OF A CKD DIAGNOSIS CODE, BY COMORBIDITY, 2010 Medicare patients age 65 & older & MarketScan patients age 50–64, alive & eligible for all of 2010. CKD claims as well as other diseases identified in 2010.

7. CUMULATIVE PROBABILITY OF A PHYSICIAN VISIT AT MONTH 12 AFTER CKD DIAGNOSIS, BY DATASET & PHYSICIAN SPECIALTY, 2010 TABLE 2.9 (VOLUME 1) Patients alive & eligible all of 2009. CKD diagnosis represents date of first CKD claim during 2009; physician claims searched during 12 months following that date.

8. DEFINITION OF CKD Structural or functional abnormalities of the kidneys for >3 months, as manifested by either: 1. Kidney damage, with or without decreased GFR, as defined by pathologic abnormalities markers of kidney damage, including abnormalities in the composition of the blood or urine or abnormalities in imaging tests 2. GFR <60 ml/min/1.73 m 2, with or without kidney damage

9. ACUTE VS. CHRONIC VS. ACUTE ON CHRONIC Acute Kidney Failure: >0.3mg/dL increase serum Creatinine/48hr or increase in serum Creatinine by 50% from baseline Chronic Kidney Failure: Stages of Chronic Kidney Disease (Stage 1-5) Definition and Classification of CKD GFR (eGFR <60ml/min) Proteinuria (Albumin Creatinine Ratio (ACR) >30mg/g) >3months Etiology Most chronic starts out with episodes of Acute Acute does not necessarily become chronic (but every acute episode needs timely fup assessment to ensure reversible does not become irreversible)

10. RISK FACTORS -WHEN IT ISN’T DIABETES?

11. WHEN TO SUSPECT SOMETHING IS WRONG WITH THE BEANS? SCREENING TOOLS (SCORED survey) Patient-initiated Score >3 = 20% chance of having CKD HISTORY Family (PCKD; AI; GN) Personal (nephrolithiasis; reflux/recurrent infxn) >10 yrs DM and/or HTN CLINICAL Edema; Urinary Sxs; Change in urinary patterns ABNORMAL LABS Proteinuria (with or without increase creatinine) Increase in creatinine (baseline vs. absolute) IMAGING Incidental findings; chronic obstruction/reflux; congenital

12. CASES Case#1 63 yo Woman with 25 yr hx of HTN, 15 yr hx of DM2 out of care for 10 years – here to re-establish care Case #2 38 yo African-American man with hx of poorly controlled htn since his early 20s with avg BPs 150-170/80-100 Case #3 28 yo G1P0 13 weeks gestation evaluated in initial prenatal visit to have BP 168/96 and 3+ protein in her urine

13. DIAGNOSTIC APPROACH Diagnosis (type of kidney disease) Comorbid conditions Severity, assessed by level of kidney function Complications, related to level of kidney function Risk for loss of kidney function Risk for cardiovascular disease

15. TO BIOPSY OR NOT TO BIOPSY? If you can’t find the Holy Grail – refer to hand out!

16. CKD death STAGES IN PROGRESSION OF CHRONIC KIDNEY DISEASE AND THERAPEUTIC STRATEGIES ComplicationsComplications 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 NormalNormal Increased risk Kidney failure DamageDamage  GFR

17. CKD - STAGES

18. TREATMENT APPROACH Specific therapy, based on diagnosis Evaluation and management of comorbid conditions Slowing the loss of kidney function Prevention and treatment of cardiovascular disease Prevention and treatment of complications of decreased kidney function Preparation for kidney failure and kidney replacement therapy Replacement of kidney function by dialysis and transplantation, if signs and symptoms of uremia are present.

19. EVALUATION AND MANAGEMENT OF COMORBID CONDITIONS HYPERTENSION DIABETES MELLITUS CARDIOVASCULAR DISEASE HYPERLIPIDEMIA ANEMIA BONE DISEASE

20. CASES Case#1 63 yo Woman with 25 yr hx of HTN, 15 yr hx of DM2 out of care for 10 years – here to re-establish care Case #2 38 yo African-American man with hx of poorly controlled htn since his early 20s with avg BPs 150-170/80-100 Case #3 28 yo G1P0 13 weeks gestation evaluated in initial prenatal visit to have BP 168/96 and 3+ protein in her urine

21. SLOWING THE LOSS OF KIDNEY FUNCTION Treat Hypertension to goal Avoid nephrotoxic medications NSAIDs Antibiotics Phosphate-containing cathartics Cox-2 inhibitors Healthy lifestyle changes DM2 – glycemic control ACEI/ARB

22. PREVENTION AND TREATMENT OF COMPLICATIONS OF DECREASED KIDNEY FUNCTION METABOLIC ABNORMALITIES ELECTROLYTE DISTURBANCES ACIDOSIS MALNUTRITION UREMIA VOLUME OVERLOAD

23. PREPARATION FOR KIDNEY FAILURE AND KIDNEY REPLACEMENT THERAPY Discussion regarding need for kidney replacement therapy should begin at least 1 year before the anticipated start of dialysis or when the GFR <30ml/min/1.73m2 Kidney transplant is treatment of choice for patients with ESKD

24. REPLACEMENT OF KIDNEY FUNCTION Dialysis Transplantation Types of Dialysis Access Modalities AV fistula -> 1 to 6 mos to mature AV graft -> 2 to 3 weeks to use Catheter -> immediate use

25. KEY POINTS TO LOVE THE KIDNEYS THINK ABOUT WHO IS AT RISK – USE SCORED TOOL AS GUIDE DEVELOP YOUR DIAGNOSTIC APPROACH – DISTINGUISH ACUTE FROM CHRONIC AND FOLLOW-UP ABNORMALITIES MINIMIZE RISK FOR PROGRESSION – USE CAUTION WITH MEDS AND OPTIMIZE TREATMENT OF RISK FACTORS USE MEDICATIONS WISELY AND JUDICIOUSLY – MONITOR RESPONSE REFER EARLY FOR GUIDANCE AND PLANNING LEARN HOW TO TALK ABOUT CKD WITH YOUR PATIENTS