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.

Kidney Disease Workup – When to

refer to NephrologistFamily Practice Review

Feb 2013 4:30-5:30

Jeff Kaufhold MD, FACPMaster Physician, Ohio University Heritage School of MedicineNephrology Associates of Dayton

Renal ReviewNow Kidney Disease- Work-up & When to Refer

to a Nephrologist - What Drugs Not to Prescribe and What Drugs Work for HypertensionMark D. Oxman, D.O.

5:30 p.m. - 6:30 p.m.Cloudy with Occasional Chance of Crystals: What You CanLearn 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 inhibitorsB. Referral to a nephrologistC. Use of DHP calcium Channel BlockerD. Control of Diabetes to A1c < 8.0E. The nature of the underlying renal Disease

New TerminologyARF - 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 6.487.322Pakistan 159.196.336 4.331.076Philipines 86.241.697 2.346.281Vietnam 82.662.800 2.248.914

Assumes 2.72 % incidence

CKD StagesStage 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

----Stage 3--- Stage 4 Stage 5

GFR

Preparation of the Patient Manage CRF

Stages 1, 2, 3.

Control BPPreferentially with ACE

Control Diabetes with Target A1c < 8, based on the DCCT, ideally < 6.5Careful with drug dosing

Prevent Hyper PTHVit D

Calcium acetate

Phosphate binder

Diet Education

Preparation of the PatientStage 4 and 5

Manage Fluids

Dialysis education

Access Placement

Prevent anemia

Prevent Malnutrition

Start ACE?

metolazone

NKF program

AV fistula, PD cath

Epogen, Iron

This can get tricky

Stop ACE?

Medical treatment in CKD

Which drugsTo avoid, andWhich drugs Work for HTN

What Drugs to Avoid

Drugs to avoid when GFR is less than 40:NSAID’sBactrim IV ContrastFleets EnemasMetformin, 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

JNC 7 Dec 2003

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, 2008Figure 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, 2009Figure 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, 2008Figure 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

equationFigure 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)

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.

Only about 30 %

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 THEIRFIRST HEART ATTACK.

Beta BlockerAspirinStatinrestart 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 PresentationPhysical Exam:

BP 170 / 110 Pulse 85

Edema 2 +

Case PresentationSpecial populations help define your approach.

African Americans:

CHF

Diabetics:

Case PresentationSpecial 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 Presentation56 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 Presentation56 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 Presentation56 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.

Case56 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 Presentation56 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?

CaseUric acid level is 12

Creatinine 1.4

K 3.8

Glucose 244 (nonfasting)

CaseStarted Allopurinol for gout.

Pt started exercising and watching diet.

Sugars normalized without treatment.

Joint National CommissionJNC 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 HypertensionNormal

Prehypertension

Stage 1

Stage 2

< 120 / 80

120 -139 / 80-89

140-159 / 90-99

> 160 / >100

Treatment of Hypertension

Stage 1 or Single agent – HCTZ for most pts. B-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

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 htnI 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 NephrologistIf 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 inhibitorsB. Referral to a nephrologistC. Use of DHP calcium Channel BlockerD. Control of Diabetes to A1c < 8.0E. The nature of the underlying renal Disease