Transcript CKD for the residents_revised


CKD FOR THE INTERNIST
ALISON LANDREY MD
CHARLIE MACLEAN, MD AND VIRGINIA HOOD, MD
July
2014
LEARNING OBJECTIVES
• Identify and categorize CKD
• Perform an appropriate evaluation for underlying
causes of CKD
• Identify and modify risk factors for progression of
CKD
• Understand and monitor for metabolic and
hematological complications of CKD
• Renally dose medications
• Know when to refer to nephrology
• Be able to explain CKD to patients
DEFINITIONS!
• CKD:
• either kidney damage OR GFR <60 mL/min/1.73m2 for >3 mo
• Kidney damage:
• abnormal pathology, imaging, U/A
• Proteinuria:
• “microalbuminuria”:
•
30-300 mg/g
•
>3 g/day (>3000 mg/g spot protein/creat)
•
Note dip picks up mostly albumin
• Nephrotic range proteinuria:
• If protein on dip – this is abnormal. Repeat up to 2-3 times to see if
transient/benign etiology. If persistent get a spot protein/creatinine
• eGFR:
• MDRD equation: Age, serum cr, gender, race (black or non-black)
• If serum creatinine is in normal range eGFR is less accurate for an
individual : 24 hour urine collection for creatinine clearance
measurement help with accuracy in limited circumstances.
• Note: a complete 24 h urine collection should contain creatinine amount of
•
15-20 mg/kg/day women; 20-25 mg/kg/day men
WHO SHOULD BE SCREENED?
WHAT CONSTITUTES SCREENING?
Screening: yearly serum Cr AND urine prot or alb/creat
• Metabolic syndromes
• Diabetes
• Obesity
• Cardiovascular disease
• Hypertension
• Hyperlipidemia
• Smoking
• Infections
• Human immunodeficiency virus (HIV)
• Hepatitis C virus infection
•
•
•
•
Malignancy
Family history of kidney disease (e.g. PKD)
Nephrotoxic drugs
History of AKI (!)
2002 STAGING
2012 STAGING WITH
PROGNOSTICATION
EXAMPLES
• Cr 1.6 GFR 40, urine protein/cr= 300 mg/g
• Stage 3b A2
• Cr 0.9 GFR 65, urine protein/cr =100 mg/g
• Stage 2 A2
• Cr 3.3 GFR 29, urine protein/cr =1g/g
• Stage 4 A3
• Cr 1.2 GFR 55, urine protein/cr 500 mg/g
• Stage 3a, A3
• Cr 1.4 GFR 50, urine protein/cr 20 mg/g
• Stage 3a A1
MKSAP 30
A 25 yo W with no PMH comes in for an evaluation before
undergoing nephrectomy for a living related donor kidney
transplant to her brother.
PE: normal temperature, BP 116/68, P 72, RR 18 weight 135 lb,
BMI 23
Serum creatinine 0.8 mg/dl
Urine cr 47 mg/dL -> Creatinine clearance 26 mL/min
24 hr urine volume 650 mL/24 hr
Protein 50 mg/24 hr cr 475 mg/24 hr
CT abdomen normal
Which is the next most appropriate step?
A) Measure cystatin C
B) Reject as a potential donor
C) Repeat timed urine collection
D) Use the MDRD equation
MKSAP 30
A 25 yo W with no PMH comes in for an evaluation before
undergoing nephrectomy for a living related donor kidney
transplant to her brother.
PE: normal temperature, BP 116/68, P 72, RR 18 weight 135 lb,
BMI 23
Serum creatinine 0.8 mg/dl
Urine cr 47 mg/dL -> Creatinine clearance 26 mL/min
24 hr urine volume 650 mL/24 hr
Protein 50 mg/24 hr cr 475 mg/24 hr
CT abdomen normal
Which is the next most appropriate step?
A) Measure cystatin C
B) Reject as a potential donor
C) Repeat timed urine collection
D) Use the MDRD equation
LEARNING OBJECTIVES
• Identify and categorize CKD ✔
• Perform an appropriate evaluation for underlying
causes of CKD
• Identify and modify risk factors for progression of CKD
• Understand, monitor for and if possible modify risk for
cardiovascular, metabolic and hematological
complications of CKD
• Renally dose medications
• Know when to refer to nephrology
• Be able to explain CKD to patients
Major Causes of Severe Chronic Kidney
Disease
• Diabetes mellitus
44.9 %
• Type 1 3.9
• Type 2 41.0
•
•
•
•
•
•
•
•
Hypertension 27.2 %
Glomerulonephritis 8.2 %
Chronic interstitial nephritis or obstruction 3.6 %
Hereditary or cystic disease 3.1 %
Secondary glomerulonephritis or vasculitis 2.1 %
Neoplasms or plasma-cell dyscrasias 2.1 %
Miscellaneous conditions 4.6 %
Uncertain or unrecorded cause 5.2%
ONCE CKD IS ESTABLISHED, IS ANY
FURTHER TESTING INDICATED?
• Urinalysis with microscopic sediment analysis
• If abnormal sediment -> referral for biopsy may be indicated
• if hematuria and/or proteinuria consider
• ANA/C3/C4, ANCA
• HIV, Hep C/hep b
• SPEP, serum free light chains, urine immunofix
• Kidney Ultrasound
• Kidney size can be helpful in diagnosis of etiology
• Cystic kidney disease
• Hydronephrosis
• Diabetic kidney disease: special considerations
• Typically with proteinuria and larger kidneys
• Typically accompanied by retinopathy, but not always
• Consider other causes if the degree of kidney disease does not
fit with the diabetes clinical picture
MKSAP 1
A 35 yo W with a history of type 1 diabetes x 10 years is evaluated for 1 mo
of progressive b/l LE edema. 4 months ago her urine albumin-creatinine
ratio was 100 mg/g. Medications are enalapril, glargine, aspart and ASA.
On PE BP is 162/90
CV lung and fundoscopic exam normal
3+ pitting edema b/l to the thighs
A1C 7.1%
Albumin 3 g/dL
Serum cr 1.1 mg/dL
U/A 3+ protein, 2+ blood, 8-10 dysmorphic erythrocytes
Urine protein-cr ratio: 5.2 mg/mg
Kidney US: 12.2 cm/12.7 cm kidneys
What is the next most appropriate step in management?
A) Cystoscopy
B) Kidney biopsy
C) Spiral CT A/P
D) Observation
MKSAP 1
A 35 yo W with a history of type 1 diabetes x 10 years is evaluated for 1 mo
of progressive b/l LE edema. 4 months ago her urine albumin-creatinine
ratio was 100 mg/g. Medications are enalapril, glargine, aspart and ASA.
On PE BP is 162/90
CV lung and fundoscopic exam normal
3+ pitting edema b/l to the thighs
A1C 7.1%
Albumin 3 g/dL
Serum cr 1/1 mg/dL
U/A 3+ protein, 2+ blood, 8-10 dysmorphic erythrocytes
Urine protein-cr ratio: 5.2 mg/mg
Kidney US: 12.2 cm/12.7 cm kidneys
What is the next most appropriate step in mgmt?
A) Cystoscopy
B) Kidney biopsy
C) Sprial CT A/P
D) Observation
MKSAP 40
A 59 yo W with CAD HTN and HLD comes for a routine
evaluation. Meds are clopidogrel, metoprolol, simvastatin
and ASA.
On PE BP is 135/82 BM 32
Fasting glucose 98
TC 190 HDL 45 LDL 100 TG 225
sCR 1.4 U/A normal
Which of the following studies should be performed next?
A) 24 hr urine collection for protein
B) Kidney US
C) Spot urine albumin-creatinine ratio
D) No further studies
MKSAP 40
A 59 yo W with CAD HTN and HLD comes for a routine
evaluation. Meds are clopidogrel, metoprolol, simvastatin
and ASA.
On PE BP is 135/82 BM 32
Fasting glucose 98
TC 190 HDL 45 LDL 100 TG 225
sCR 1.4 U/A normal
Which of the following studies should be performed next?
A) 24 hr urine collection for creatinine clearance
B) Kidney US
C) Spot urine albumin-creatinine ratio
D) No further studies
LEARNING OBJECTIVES
• Identify and categorize CKD ✔
• Perform an appropriate evaluation for underlying
causes of CKD ✔
• Identify and modify risk factors for progression of CKD
• Understand, monitor for and if possible modify risk for
cardiovascular, metabolic and hematological
complications of CKD
• Renally dose medications
• Know when to refer to nephrology
• Be able to explain CKD to patients
MODIFY RISK OF PROGRESSION OF CKD
• Most important modifiable risk factors for
progression:
• HTN, higher amount of proteinuria
• Proteinuria
• Should be on an ACE/ARB regardless of BP
• Goal <300-500 mg/g
• DM
• Goal A1C: as close to 7 as possible if this can be achieved
without causing hypoglycemia – not proven to slow
progression
• dietary protein restriction to 0.5-0.7 g/day if more advanced
CKD: delay progression to uremia and small trials show
delay progression of CKD
• Bicarb if metabolic acidosis (more later)
Relative Risk
HYPERTENSION TREATMENT EFFECT
MIRRORS OBSERVATIONAL RISK EFFECT
18
16
14
12
10
8
6
4
2
0
16
8
4
1
115/75
2
135/85
155/95
175/105
Blood Pressure (mmHg)
195/115
Lewington et al, Lancet 2002
High blood pressure is the most modifiable risk factor for reducing
stroke and preventing progression of kidney & cardiovascular disease
HYPERTENSION MGMT
• CKD patients with HTN often require two agents:
• Tip from Dr. Hood: many patients do better on two drugs at lower
doses rather than one at higher dose
• ACE-I/ARB 1st choice
• Proven to slow progression of CKD in patients with proteinuria
• Has not been shown to slow progression of CKD in patients with
proteinuria <500 mg/day BUT RAAS inhibition may have CV benefits
too
• Studies have not shown benefit to combination of ACE-I/ARB
• Diuretics, esp if e/o fluid overload (edema e.g.)
• Thiazide if GFR >30
• Loop if GFR <30 – DON’T BE AFRAID of furosemide in CKD
• *Remember to advise on salt restriction as well*
• Other agents to consider if needed
• BB esp if CAD/angina
• CCBs: nondihydropyridines (diltiazem, verapamil) also have an
antiproteinuric effect but dihydropyridines better for BP control
• Ok to add spironolactone if GFR >30 and K low enough
• Hydralazine, alpha blocker, clonidine if need 4-5 drugs
MORE ON ACE-I/ARB
ARBs appear to be as beneficial
as ACE-I in CKD but have less
data
Trials showing benefit excluded
hypovolemic pts and pts with
RAS
BLOOD PRESSURE GOALS
• Goal BP <140/90 according to JNC8 for all CKD
• ? Goal <130/80 for CKD with albuminuria >30 mg/day
or proteinuria >500-1000 mg/day
• MDRD study: 3 year f/u
• <1 g/day proteinuria: no benefit to aggressive BP
control (target 125/75) vs. target 140/90
• Evidence for delayed progression with tighter BP
control if proteinuria/albuminuria
• ACE-I used in both groups (about ½ of all enrolled)
• Consider more relaxed goals <150/90 if elderly (>60?
>80?)
MKSAP 72
A 70 yo W comes for routine f/u for recently diagnosed
CKD and HTN. She is asymptomatic. Her only med is
lisinopril, which was titrated up to the maximal dose over
the last 3 months. She is adherent to this and a sodium
restricted diet.
On PE VS show BP 160/90 and she has trace b/l pedal
edema
K 5.0, sCr 1.3, Urine protein-cr ratio 2.1 mg/mg
Which of the following is the most appropriate treatment
for this patient?
A) Hydrochlorothiazide
B) Losartan
C) Metoprolol
D) Verapamil
MKSAP 72
A 70 yo W comes for routine f/u for recently diagnosed
CKD and HTN. She is asymptomatic. Her only med is
lisinopril, which was titrated up to the maximal dose over
the last 3 months. She is adherent to this and a sodium
restricted diet.
On PE VS show BP 160/90 and she has trace b/l pedal
edema
K 5.0, sCr 1.3, Urine protein-cr ratio 2.1 mg/mg
Which of the following is the most appropriate treatment
for this patient?
A) Hydrochlorothiazide
B) Losartan
C) Metoprolol
D) Verapamil
LEARNING OBJECTIVES
• Identify and categorize CKD ✔
• Perform an appropriate evaluation for underlying
causes of CKD ✔
• Identify and modify risk factors for progression of
CKD✔
• Understand, monitor for and if possible modify risk for
cardiovascular, metabolic and hematological
complications of CKD
• Renally dose medications
• Know when to refer to nephrology
• Be able to explain CKD to patients
CARDIOVASCULAR RISK
• 17 fold higher risk of CV events in CKD vs. non-CKD
patients (Should CKD be considered a CAD risk
equivalent?)
• Most randomized trials of CV disease have
excluded patients with CKD IV and V
• Lifestyle recommendations remain key
• Smoking cessation
• Exercise
• Diet
• Remember again: low sodium
• Aspirin?
• Assess risks and benefits and use SDM
• E.g. if CV risk estimated to be >10% and no excess bleeding
risk, consider adding 81 mg ASA daily
STATIN THERAPY?
• Lancet 2011: CKD 3-5: risk reduction from 13.4% to 11.3% over 5
years for all major CV events. Does not modify risk of progression
of CKD
• Still take into account all risk factors (e.g. CV/framingham risk)
Prevalence of chemical and metabolic consequences of
CKD increase with decreasing GFR, notably < 60 ml/min
JASN 20: 164–171, 2009
METABOLIC
COMPLICATIONS/MINERAL AND BONE
DISORDERS
• Hyperkalemia
• esp with ACE/ARB, K-sparing diuretic
• Metabolic Acidosis
• Treat with sodium bicarb if serum bicarb <22
• Shown to slow progression of kidney disease
• Dr. Hood recommends baking soda (1/2 tsp/day)
• Metabolic Bone disease - complex
• For CKD 3 and above: check PTH, Vitamin D-25, calcium
and phosphorus
• In general: refer to nephrology if PTH or phosphorus high
Moe, SM et al. ACKD: 3-12, 2007
A REFRESHER ON SECONDARY
HYPERPARATHYROIDISM IN CKD
MORE ON PTH/PHOS/CA PHYSIOLOGY
• In CKD 2-3, increased PTH helps maintain normal
serum Ca
• Stage 4-5: sustained hyperphosphatemia leads to:
• Even higher levels of PTH which further suppresses 1,25 Vit D
production and can lead to hypocalcemia
• Increased cal-phos product -> increased vascular
calcification: may contribute to CV mortality
• Maintaining optimal balance between treating vitamin D
deficiency and preventing extraosseous calcification is
challenging
• Achieving target phos and cal levels priority over PTH level
Calcium and Phosphorus Management in CKD stage 3, 4 and 5
goals: serum Ca 8.4 - 9.5 mg/dl
serum P 2.7 - 4.5 mg/dl
intact PTH ? 35 - 70 pg/ml - stage 3
? 70 - 110 pg/ml - stage 4
? 150 - 300 pg/ml – stage 5
Strategies to maintain normal
• reduce dietary phosphorus intake < 1 g/d
• use phosphate binders with meals to keep P at goal
(Ca CO3, calcium acetate, sevelamer CO3,
lanthanum CO3)
• Avoid calcium based phos binders if ca-phos
product high and/or PTH too low
• Replace low Vit D-25 with cholecalciferol
• give 1,25 D3 (calcitriol) 0.25-0.5 mcg/d if PTH high (?
>2x N) but avoid oversuppression also
PREVALENCE OF TYPES OF BONE DISEASE AS
DETERMINED BY BONE BIOPSY IN PATIENTS WITH CKDMBD
AD, adynamic bone; OF, osteitis fibrosa; OM, osteomalacia.
BONE DISEASE DISEASE IN CKD/”RENAL
OSTEODYSTROPHY”: MANY FLAVORS
• Adynamic bone disease
• Low bone turnover/low PTH: common in CKD 5
• Functional hypoparathyroidism may contribute (PTH<100)
• E.g. Oversupplementation of vitamin D/calcium
• Osteitis fibrosa cystica
•
•
•
•
High turnover bone disease/high PTH: Subperiosteal bone reabsorption
Asymptomatic if early, bone pain, fractures if advanced
Brown tumors: erosive osteolytic lesions
Tx: vit d analogs, lower serum phos
• Osteomalacia
• Low bone turnover: hypocalcemia, hypophosphatemia, aluminum
toxicity
• Osteoporosis
• DXA inaccurate in CKD 3 + because of other bone abnormalities –
may be present if fractures plus hx of steroids, vit d deficiency, etc.
• Bone biopsy if high suspicion is required prior to starting any therapy
• Bisphosphonates may contribute to adynamic bone disease in CKD 4/5
MKSAP 19
A 59 yo W is evaluated for a 2 wk hx of right hip pain. She has
CKD treated with peritoneal dialysis. Meds are epoetin alfa,
calcium acetate, calcitriol, and a MVI.
PE: VS wnl, tender over right lateral trochanter, rotation at the
hip elicits pain
Labs: phos 5.6, ca 10.2 ALP 86 PTH 21
1,25 OH D =52 25-OH D =15
Plain radiograph of R hip shows diffuse osteopenia. An area
of lucency is seen along the medial aspect of the femoral
neck consistent with a stress fracture.
Which is the most likely cause of this patient’s bone disease?
A)Adynamic bone disease
B)B2-microglobulin-associated amyoidosis
C)Osteitis fibrosa cystica
D)Osteomalacia
MKSAP 19
A 59 yo W is evaluated for a 2 wk hx of right hip pain. She has
CKD treated with peritoneal dialysis. Meds are epoetin alfa,
calcium acetate, calcitriol, and a MVI.
PE: VS wnl, tender over right lateral trochanter, rotation at the
hip elicits pain
Labs: phos 5.6, ca 10.2 ALP 86 PTH 21
1,25 OH D =52 25-OH D =15
Plain radiograph of R hip shows diffuse osteopenia. An area
of lucency is seen along the medial aspect of the femoral
neck consistent with a stress fracture.
Which is the most likely cause of this patient’s bone disease?
A)Adynamic bone disease
B)B2-microglobulin-associated amyoidosis
C)Osteitis fibrosa cystica
D)Osteomalacia
ANEMIA IN RENAL DISEASE
• Secondary to:
• deceased erythropoietin production by kidney
• Anemia of kidney disease is usually apparent by
CKD 4
• Diagnosis of exclusion
• iron deficiency, B12 deficiency, hemolysis
• Epo levels NOT recommended
Iron Replacement in CKD
 Monitor: serum ferritin, iron saturation (TSAT)
 Goal: serum ferritin 100-600 ng/ml, TSAT 20-50%
 Oral ferrous sulfate 325 mg 1-3 times/day
– often poorly tolerated or ineffective
 intravenous preparations: ferric gluconate
Safety concerns:
infusion reactions
concurrent active infection
WHAT IS THE TARGET HGB IN ANEMIA
OF RENAL DISEASE?
9-11 g/dL
CHOIR 2006: RCT to Hb 11.3 v 13.5 in 1432 with GFR 15-50
Adverse CV outcomes in 13.5% (Hb 11.3) v 17.5% (Hb 12.6)
No change in QOL measures
CREATE 2006: RCT to Hb 10.5-11.5 v 13-15 in 603, GFR 15-35
No difference in time to first CV event (but underpowered)
Better QOL (vitality score SF36) in high Hb group
TREAT 2010: RCT in 4000 CKD (GFR 20-60), DM2 , Hb < 11;
Intervention: darbepoietin v placebo;
Goal: Hb 13 g/dl or rescue if < 9 g/dl;
Outcome: all cause mortality, CV morbidity no different
but higher rate of stroke and thrombolic events
Erythropoietin (ESAs) use in CKD 3-5
 prior to initiating treatment:
control BP (< 160/90 mmHg)
ensure adequate B12, Fe (% saturation > 20)
check for treatable inflammation
 during ongoing treatment:
monitor Hb or HCT every 2-4 weeks
monitor Fe saturation, ferritin every 3 months
maintain Fe sat 20-50%, ferritin < ? 600 ng/ml
keep BP well controlled
MKSAP 43
A 35 yo W with a history of stage 4 CKD and HTN 2/2 FSGS
is evaluated for a 2 month hx of fatigue. She has no SOB,
melena or menorrhagia. Meds include lisinopril, ASA,
sevelamer, and furosemide. Family hx negative for
anemia.
On PE she has pallor, stool negative for occult blood.
Labs:
Hgb 8.6 WBC 5600 MCV 82
Retic 0.5% Ferritin 25, Transferrin saturation 10%, B12 600
Folate 14
Which is the next most appropriate step?
A) Begin epo alfa
B) Begin iron
C) Measure serum erthropoietin
D) Schedule bone marrow examination
MKSAP 43
A 35 yo W with a history of stage 4 CKD and HTN 2/2 FSGS
is evaluated for a 2 month hx of fatigue. She has no SOB,
melena or menorrhagia. Meds include lisinopril, ASA,
sevelamer, and furosemide. Family hx negative for
anemia.
On PE she has pallor, stool negative for occult blood.
Labs:
Hgb 8.6 WBC 5600 MCV 82
Retic 0.5% Ferritin 25 B12 600 Folate 14
Which is the next most appropirate step?
A) Begin epi alfa
B) Begin iron
C) Measure serum erthropoietin
D) Schedule bone marrow examination
LEARNING OBJECTIVES
• Identify and categorize CKD ✔
• Perform an appropriate evaluation for underlying
causes of CKD ✔
• Identify and modify risk factors for progression of
CKD✔
• Understand, monitor for and if possible modify risk for
cardiovascular, metabolic and hematological
complications of CKD✔
• Renally dose medications
• Know when to refer to nephrology
• Be able to explain CKD to patients
AVOID NEPHROTOXIC AGENTS!
• NSAIDs and Cox-2 inhibitors
• Iodinated Contrast
• Magnesium and phosphate containing cathartics
• Milk of mag, mag citrate
• Discontinue:
• Metformin if GFR <50
• Risk of lactic acidosis
• Bisphosphonates if GFR <50
• Risk of adynamic bone disease
OTHER MEDS MAY REQUIRE
ADJUSTMENT
 For those with or at risk for CKD:
 Avoid glyburide, especially in the elderly (longer half life,
more hypoglycemia)
 Benadryl has a longer half life, as it is renaly excreted
 In gout, treat to a target uric acid level rather than a
specific dose reduction of allopurinol – lower uric acid level
may also slow risk of progression of CKD, studies underway
 Colchicine also renally dosed – relevant if avoiding NSAIDs and
prednisone for acute gout tx
 Antibiotics, antiepileptics often require renal dosing
MKSAP 36
A 55 yo M comes for a new patient evaluation. He was diagnosed
with type 2 DM 15 years ago. He also has HTN and a 1-year hx of R
knee OA that is well controlled with maximal-dose ibuprofen. He
has not been evaluated by a physician in 3 yeas and has been out
of his HCTZ, losartan, metformin and pravastatin for 2 years.
BP 146/92, BMI 31, cardiopulmonary exam normal, b/l pedal edema
to mid shin
Labs: glucose 230 nonfasting
Potassium 5.7 sCr 2.5 urine protein-creatinine ratio 0.46 mg/mg U/A
3+ protein, 2+ glucose
In addition to initiating furosemide, which of the following is the
most appropriate initial step in managing his CKD?
A)Begin HCTZ
B)Begin losartan
C)Begin spironolactone
D)Discontinue ibuprofen
MKSAP 36
A 55 yo M comes for a new patient evaluation. He was diagnosed
with type 2 DM 15 years ago. He also has HTN and a 1-year hx of R
knee OA that is well controlled with maximal-dose ibuprofen. He
has not been evaluated by a physician in 3 yeas and has been out
of his HCTZ, losartan, metformin and pravastatin for 2 years.
BP 146/92, BMI 31, cardiopulmonary exam normal, b/l pedal edema
to mid shin
Labs: glucose 230 nonfasting
Potassium 5.7 sCr 2.5 urine protein-creatinine ratio 0.46 mg/mg U/A
3+ protein, 2+ glucose
In addition to initiating furosemide, which of the following is the
most appropriate initial step in managing his CKD?
A)Begin HCTZ
B)Begin losartan
C)Begin spironolactone
D)Discontinue ibuprofen
LEARNING OBJECTIVES
• Identify and categorize CKD ✔
• Perform an appropriate evaluation for underlying
causes of CKD ✔
• Identify and modify risk factors for progression of
CKD✔
• Understand, monitor for and if possible modify risk for
cardiovascular, metabolic and hematological
complications of CKD✔
• Renally dose medications✔
• Know when to refer to nephrology
• Be able to explain CKD to patients
HELP! WHEN TO ENLIST OUR
NEPHROLOGY FRIENDS
• If etiology unclear and/or may need biopsy
• Any CKD 4 – need to start discussion of planning for
RRT at this point
• ?CKD 3b if challenging management issues
• BP difficult to control
• Hyperphosphatemia and/or PTH> 150?
• Metabolic acidosis?
LEARNING OBJECTIVES
• Screen for, Identify and categorize CKD ✔
• Perform an appropriate evaluation for underlying
causes of CKD ✔
• Identify and modify risk factors for progression of
CKD✔
• Understand, monitor for and if possible modify risk for
cardiovascular, metabolic and hematological
complications of CKD✔
• Adjust medications according to renal function ✔
• Know when to refer to nephrology✔
• Manage your panel of CKD patients and be able to
explain CKD to patients
PATIENT HANDOUT:
Decreased Kidney Function
Decreased Kidney Function
What is the function of the kidneys?
What do I need to do if I have decreased kidney function?
The kidneys have two major functions in your body:
The most important things to be aware of are:
 filtering waste products and extra salt out of your blood
 regulating the amount of water in your body
What happens when your kidneys don’t work correctly?
It is normal to lose some kidney function with age. Fortunately, humans have a lot of
kidney reserve, so you can lose a lot of function and not have any problems.
Loss of kidney function is sometimes called “Chronic Kidney Disease (CKD)” or “Renal
Disease”.
 Stay well hydrated—the kidneys need a steady flow of fluids to keep working well!
 If you get sick and can’t stay hydrated (for example with a stomach bug) check with
your doctor to see if you should temporarily stop any of your medications.
 Avoid over the counter medications that may affect kidney function (unless cleared
by your doctor):
o Ibuprofen (Advil, Motrin, and others)
o Naproxen (Aleve, Naprosyn, and others)
What are the causes of decreased kidney function?
The most common reason for minor changes in kidney function is aging.
Other common reasons for decreased kidney function are high blood pressure and
diabetes.
Other factors that may affect kidney function are obesity, smoking, and a family history
of kidney disease.
What is the treatment for decreased kidney function?
For most people with decreased kidney function, no specific treatment is needed.
There are some things your doctor and other members of your healthcare team will
focus on and some things that you should be aware of also.
Your doctors will focus on:
 controlling blood pressure, cholesterol and blood sugar (if you have diabetes)
 avoiding or adjusting medications that may affect your kidneys
o Many supplements (Chromium, Creatine, Licorice, and others)
 If you are going to have a CT or CAT scan that involves a special kind of dye called
contrast, make sure to tell the ordering doctor about your decreased kidney
function.
For more information
 National Kidney Foundation
o http://www.kidney.org
 National Kidney Disease Education Program
o http://nkdep.nih.gov/
A CASE FROM NEJM
A 54-year-old woman with an 11-year history of type 2
diabetes presents for care. She was first noted to have
proteinuria 4 years earlier; her serum creatinine level
then was 1.1 mg per deciliter (97 μmol per liter). Her
urinary protein excretion has progres- sively increased to
2.8 g per 24 hours, and her serum creatinine level to 3.1
mg per deciliter (274 μmol per liter). The estimated
glomerular filtration rate (GFR) is 26 ml per minute per
1.73 m2 of body-surface area. Her blood pressure is
155/90 mm Hg, and the glycated hemoglobin level is 7.6
mg per deciliter. The medications she is currently taking
include an oral hypoglycemic agent, an angiotensinconverting–enzyme (ACE) inhibitor, a statin, and a
thiazide diuretic. How should her case be managed?
JOURNAL CLUB
• NEJM 2007: