Ruth Ann Fritz RN CNS-BC CCRN CNN April 16, 2011.

Ruth Ann Fritz RN CNS-BC CCRN CNN April 16, 2011

Objectives Identify normal changes in GU system Identify causes and care of End Stage Renal Disease in the older adult population Calculate GFR Discuss pharmacological management of Diabetes, Hyperlipidemia, and Hypertension in the geriatric renal patient Identify proper renal doses for classes of medications Name two interventions to protect patients kidneys

AGE RELATED CHANGES Decreased body mass and malnutrition Genitourinary Male- Enlarged prostate - difficulties emptying bladder Females - Urgency, frequency, nocturia - Thin mucosa, loss of muscle tone BPH, incontinence, and UTI complications Renal changes Decreased renal blood flow Decreased tubular function Decreased glomerular filtration rate (GFR)

AGE RELATED CHANGES Renal changes cont. Decreased ability to regulate H+ ion and concentrate urine Nephron degeneration - Decrease GFR (by age 70 - 33- 50% less) More difficulty maintaining homeostasis and fluid balance Glomerular filtration rates decrease 6.5ml/ 10 years Creatinine level alone not reflect renal function as decreased body mass and less creatinine production

ANATOMY Kidney Renal artery Cortex Medulla 1 million nephrons each Renal pelvis Ureter

ANATOMY Nephron Glomerulus Tubules Loop of Henle Arterioles Afferent Efferent Capillaries Veins

Benign Prostatic Hypertrophy Anatomy and physiology

PHYSIOLOGY Endocrine function Renin, Prostaglandins, Erythropoietin Metabolic function Activation Vitamin D Gluconeogenesis - 10% Metabolism of endogenous compounds-insulin / steroids- Enzymes (Cytochrome P450) Excretory function (fluid, toxins, acid/base) Glomerular Filtration Passive Most proteins to large Tubular Secretion Active transport Proximal tubule Tubular reabsorption Water - fluid Solutes/drugs

CHRONIC KIDNEY DISEASE Incidence in elderly Older adults increased risk - CV system Due to age-related changes & BPH - renal pathology Hypertension results in 50-60 % deaths due to CRF Acute Renal Injury vs. CKD Elderly on dialysis increased by >50% in last decade Risk factors/ Causes Diabetes Mellitus and Hypertension Chronic illnesses, infections, nephrotoxic factors - examples - X ray dye, NSAIDS, antibiotics

GLOMERULAR FILTRATION RATE GFR equal to the total of the filtration rates of all the functioning nephrons in the kidney All functions associated with GFR Calculations based on BSA calculations GFR indicator of ability of kidney to eliminate drugs from the body Calculation 24hr Creatinine Clearance Estimates calculated from creatinine level, gender, age, weight, and race

GLOMERULAR FILTRATION RATE Calculation ---(NKF web site) Estimates Cockcroft-Gault Equation (CG) Modification of Diet in Renal Disease (MDRD) more accurate when GFR or < 60 Decreased GFR in elderly Predictor of adverse outcomes such as death and cardiovascular disease Requires adjustment in drug doses

GLOMERULAR FILTRATION RATE Example -(NKF web site) 22 year old black male Creatinine 1.2 GFR 98ml normal or stage 1 CKD if damage 58 year old white male Creatinine 1.2 GFR 66 ml stage 2 CKD if damage 80 year old white female Creatinine 1.2 GFR 46 ml stage 3 CKD

DEFINITION OF CKD Kidney damage for >/=3months, as defined by structural or functional abnormalities of the kidney, with or without decreased GFR, manifest by either: Pathological abnormalities; or Markers of kidney damage, including abnormalities in the composition of the blood or urine, or abnormalities in imaging tests GFR /= 3 months, with or without kidney damage

MARKERS OF CKD Proteinuria main marker Spot total protein/creatinine ratio >200 mg/g False positives or negatives / two or more positive tests Associated with complications - early detection Prognostic finding decrease in proteinuria correlated with slower loss of kidney function Hematuria Other urine sediment abnormalities casts, crystals Abnormal blood tests

STAGES OF CKD

INTERVENTIONS Increased risk for CKD GFR>90 Screen for risk factors Stage 1 GFR >/= 90 markers of damage Diagnose cause of CKD and treat Screen and treat risk factors Treat co-morbid conditions Screen and treat cardiovascular risk factors Stage 2 GFR60-89 mild complications Adjust medication doses Minimum yearly assess rate of GFR decline

INTERVENTIONS Stage 3 GFR 30-59 moderate complications Minimum bi-yearly GFR assessment Screen for complications every 3 months and treat if present Stage 4 GFR15-29 severe complications Refer for preparation for renal replacement therapy Management of complications Stage 5 GFR

PROTEINURIA MANAGEMENT Monitor spot protein/creatinine ratio goal 500-1000mg/g ACE Inhibitors/ARBs -renal/cardio protective Slow progression of diabetic kidney disease and nondiabetic kidney disease with proteinuria Reduce proteinuria May have 15% drop in GFR in week 1 - usually returns to baseline in 4-6 weeks Stop ACE Inhibitor / ARB Potassium 5.6 or higher despite treatment GFR decline > 30% in 4 months without explanation

MALNUTRITION Protein-energy malnutrition develops with CKD or with age and associated with adverse out comes Low protein Low calorie intake Anorexia Other causes proteinuria, GI issues, metabolic acidosis, chronic inflammatory state in CKD Nutrition Dietary consult complex patients Megace, protein supplements caution K level

DIABETES #1 cause of CKD Intensive management of diabetes goal Hgb A1C 6 or less Metformin (Glucophage)- risk of Lactic acid Avoid creatinine >1.5 men/>1.4 women GFR

HYPERTENSION #2 cause of CKD - complication of CKD- risk ESRD and Cardiovascular disease - JNC 7 and KDOQI Guidelines Target BP less than 130/80 or lower Lifestyle changes (CKD diet) Preferred agents Diabetic or Proteinuria ACE inhibitor or ARB Caution : If patient hypotensive and on ACE - reduced GFR Potential hyperkalemia with ACE/ARB, or with Potassium supplements with diuretics Compelling indications, - Heart failure, DM, post MI Beers list avoid Alpha blockers (Cardura), Clonidine

HYPERTENSION /FLUID MANAGEMENT Education -low sodium diet, BS control, and daily weights Monitor lab, GFR, BP, Dehydration Thiazide diuretics HCTZ, Metolazone Avoid 2.5, or has gout Loop diuretics Lasix, Demadex, Bumex All CKD stages Potassium sparing Spirolactone, Triamterene, Amiloride Caution/avoid renal disease, ACE, potassium supplements Dialysis - ESRD

ELECTROLYTES/ACIDOSIS Potassium supplementation/restriction Diuretic use CKD monitor lab, diet instructions Hemodialysis - great caution Peritoneal may need supplementation Bicarbonate metabolic acidosis Calcium Magnesium - caution Aluminum avoid (caution Sucrafate)

CARDIOVASCULAR DISEASE Risk for CVD CAD, Cerebral vascular, and or peripheral vascular disease Perfusion atherosclerosis/calcification Cardiac function CHF, LVH Most patients die of CVD not CKD Hyperlipidemia management, stop smoking, cardiac evaluations, modification of medications Potential for Digoxin Toxicity with decreasing GFR adjust dose and schedule Anticoagulation Caution Lovenox/Aggrenox

HYPERLIPIDEMIA Statin dosesGFR >/=30

INFECTION MANAGEMENT CKD patient at increased risk for infections, elderly prone to develop UTI/sepsis Antibiotics long life and some are nephrotoxic and need drug levels Check dosages Penicillin Avoid Penicillin G Amoxicillin 500mg TID or BID Avoid Imipenum/cilastatin seizures Tetracyclines except doxycycline exacerbates uremia

INFECTION MANAGEMENT Avoid Nitrofurantoin (Macrobid) metabolite cause peripheral neuritis/ nephrotoxic Aminoaglycosides if possible Examples of dosages Cipro 250-500 daily Levaquin 250 QOD** Vancomycin 1gm load/ 500mg- 750mg dose-ESRD end of treatment-Drug levels Z pack no change lasts longer Bactrim decrease 50% GFR 15-30, avoid < 15 GFR

NEUROPATHY Common complication level of CKD Encephalopathy Peripheral polyneuropathy Autonomic dysfunction Sleep disorders restless legs Peripheral mononeuropathy Dialysis, - PD/HD, transplant, Epogen, vitamins Tricylic antidepressants avoid Elavil (Amtriptiline) Beers list Anticonvulsants -Neurontin (Gabapentin) adjust dose on CKD level Lidocaine patch, Lyrica, Requib

PAIN MANAGEMENT Avoid All NSAIDS and Cox inhibitors Toradol Darvocet, Demerol, and Codeine, Benadryl (Beers list), Cymbalta avoid

GASTOINTESTIONAL CARE Antacids Laxatives avoid MOM, Mag citrate GERD treatment H2 avoid Tagament PPIs Nausea constipation, gastroparesis GI preps caution with phosphate preparations - GoLytely Enema Avoid fleets phos soda - Phos

ANEMIA MANAGEMENT Early complication of CKD increased Cardiovascular risk Target 11-12 hemoglobin Lab for anemia workup Supplemental Iron IV/Oral caution constipation Erythropoietin Therapy Procrit -predialysis/Epogen dialysis Aranesp Renal Vitamin with Folic Acid Malnutrition plays role -Albumin level

BONE AND MINERAL Abnormal mineral metabolism of CKD leads to secondary hyperparathyroidism and bone disease and other related complications (fractures) Early complication due to abnormal mineral metabolism and treatments in CKD. Can result in calcification of arterial system and cardiovascular disease

BONE AND MINERAL LabCa, phos, PTH, Vitamin D 25/ 1,25 Dietary Phosphorous Management/oral Vitamin D Phosphate Binders Ca based Tums, Phoslo Non Ca based Renagel, Fosrenal Activated Vitamin D Therapy oral/IV Calcijex /Rocaltrol Zemplar Hectoral Sensipar

HERBAL MEDICATION St John's wort and ginkgo increase metabolism of other meds Ginkgo bleeding risk if on ASA, warfarin, or ibuprofen Alfalfa, dandelion, and noni juice contain potassium If contain heavy metals and Chinese products with aristolochic acid are nephrotoxic Vasoconstrictive additives can cause hypertension

PROTECTION OF KIDNEY NSAID use risk Arthritis in elderly Contrast Protections Monitor lab prior to procedures Calculate GFR Mucomyst Sodium Bicarbonate/NS Infusion Non Ionic contrast minimal amt Avoid hypotension Avoid nephrotoxic meds/ proper dosages of meds Avoid dehydration, control co-morbids, and Educate !!

GERIATRIC MEDICATION ISSUES Polypharmacy Different providers Name brand or generic Simple dosing schedule as possible Be sure can afford try to make meds last Encourage use of aids- pillboxes, calendars Instruct relatives and caregivers - use Home health, pharmacy that delivers Caution when prescribe review meds check side effects, and interactions

QUESTIONS

Ruth Ann Fritz RN CNS-BC CCRN CNN April 16, 2011.

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