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

Stages 3, 4 & 5  Kidney damage getting worse  eGFR getting progressively lower  Risks associated  Progressive kidney disease (dialysis)  Increased cardiovascular risk  Myocardial infarction (heart attack)  Stroke  Sudden death

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