Transcript Kidney Disease Workup – When to refer to Nephrologist

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 Heritage School of Medicine
Nephrology Associates of Dayton
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.
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
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
CKD prevalence in world
Populations
 Country






Population
CKD est.
China
1.298.847.624 35.336.295
India
1.065.070.607 28.976.185
Indonesia
238.452.952 6.487.322
Pakistan 159.196.336 4.331.076
Philipines
86.241.697 2.346.281
Vietnam
82.662.800 2.248.914
 Assumes 2.72 % incidence
CKD Stages
 Stage 1. Normal function with known dz
 Stage 2. GFR 60-80
 Stage 3. GFR 30-60
 Stage 4. GFR 15-30.
 Stage 5. GFR less than 15.
 Stage 6. ESRD on dialysis.
US Population with CKD
Coresh, Selvin, Stevens. Prevalence of CKD in the US. JAMA.2007;298(17)2038.
Approach as CKD
progresses
GFR
----Stage 3---
Stage 4 Stage 5
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
Preparation of the Patient
Stage 4 and 5
 Manage Fluids
 metolazone
 Dialysis education
 NKF program
 Access Placement
 AV fistula, PD cath
 Prevent anemia
 Epogen, Iron
 Prevent Malnutrition
 This can get tricky
 Start ACE?
 Stop ACE?
Medical treatment
in CKD
Which drugs
To avoid,
and
Which drugs
Work for HTN
What Drugs to Avoid
 Drugs to avoid when GFR is less than 40:





NSAID’s
Bactrim
IV Contrast
Fleets Enemas
Metformin, Xarelto
 For GFR less than 30, need to be careful with
combinations of drugs like ACE and Spironolactone.
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.
Nat’l Health & Nutrition Exam
Survey NHANES
Control of Hypertension
80
70
60
50
Awareness
Treatment
Control
40
30
20
10
0
76-80
88-91
JNC 7 Dec 2003
91-94
99-2000
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.
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.
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.
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
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.
Mortality rates in NHANES 1999-2004
participants, by eGFR: MDRD equation
Figure 1.11 (Volume 1)
NHANES 1999–
2004 participants
age 20 & older.
Cumulative probability of a physician
visit in the year following CKD diagnosis
by physician specialty & dataset
Figure 2.10 (Volume 1)
Only about 30 %
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.
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 THEIR FIRST HEART ATTACK.
Beta Blocker
Aspirin
Statin
restart ACE inhibitor or ARB
once pt on dialysis
To prevent a vessel wall thrombus
Hall Thrombus
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
Case Presentation
 Physical Exam:

BP 170 / 110

Edema 2 +
Pulse 85
Case Presentation
 Special populations help define your approach.
 African Americans:
 CHF
 Diabetics:
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.
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???
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.
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.
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 can’t get
out of bed – too dizzy!
 He had lost 15 lbs.
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?
Case
 Uric acid level is 12
 Creatinine 1.4
 K 3.8
 Glucose 244 (nonfasting)
Case
 Started Allopurinol for gout.
 Pt started exercising and watching diet.
 Sugars normalized without treatment.
Joint National Commission
 JNC 1
1980
founded on HDFP
 JNC 2
1984
Intro of ACE, alpha B.
 JNC 3
1986
Special situations
 JNC 4
1988
Many agents 1st line
 JNC 5
1993
Back to stepped care.
 JNC 6
1997
ACE for Diabetics
 JNC 7
2003
HYPERTENSION
JNC VII Outline

Epidemiology of HTN

Evaluation of HTN

NON Pharmacologic treatments:
Wt loss, diet, exercise, alcohol

Drug treatment

Special Issues in HTN
HYPERTENSION
JNC V

"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."
Stages of Hypertension
Normal
< 120 / 80
Prehypertension
120 -139 / 80-89
Stage 1
140-159 / 90-99
Stage 2
> 160 / >100
Treatment of Hypertension
 Stage 1 or Single agent – HCTZ for most pts.
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
B-
Classes of Antihypertensives
 Diuretics
 Rate control agents
BBlocker, Verapamil, Diltiazem
 ACE/ ARB’s
 Vasodilators Dihydropyridines, Hydralazine, Alpha
blockers, Minoxidil
 Central agents: clonidine, aldomet.
Nephrology level htn
 I tell the pt that we’ll 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)
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.
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