Chronic Kidney Disease (CKD) in the Hospitalized Patient Catherine Staffeld-Coit, MD.

Chronic Kidney Disease (CKD) in the

Hospitalized Patient

Catherine Staffeld-Coit, MDCatherine Staffeld-Coit, MD

No disclosures.No disclosures.

ObjectivesObjectives

Explain the scope of CKD and its Explain the scope of CKD and its stages.stages.

Discuss options for renal replacement Discuss options for renal replacement therapy.therapy.

Review commonly seen problems in Review commonly seen problems in renal patients.renal patients.

Explore the reasons for markedly Explore the reasons for markedly higher incidence of cardiovascular higher incidence of cardiovascular disease in the renal population.disease in the renal population.

Estimating Severity of Estimating Severity of CKDCKD Can use many formulas.Can use many formulas. ALL require steady state, BUT ALL require steady state, BUT notnot

on dialysis.on dialysis. MDRD Calculator available @ MDRD Calculator available @

many sites:many sites:

Staging of CKDStaging of CKD

National Kidney Foundation

USRDS Projected Growth of USRDS Projected Growth of Prevalent Dialysis and Prevalent Dialysis and Transplant PopulationsTransplant Populations

U.S. Renal Data System, USRDS 2008 Annual Data Report, NIH, NIDDK, 2008

Geographic variations in adjusted Geographic variations in adjusted incident rates of ESRD per million incident rates of ESRD per million population, 2009, by HAS Fpopulation, 2009, by HAS Fig 1.4 ig 1.4 (Vol 2)(Vol 2)

Adj: age/gender/race; ref: 2005 ESRD patients.


Prevalent Prevalent counts & counts & adjusted adjusted rates of rates of ESRD, by ESRD, by raceraceFig 1.12 (Vol 2)Fig 1.12 (Vol 2)

December 31 point prevalent ESRD patients. Adj: age/gender; ref: 2005 ESRD patients.


Prevalent Prevalent Counts & Counts & adjusted rates adjusted rates of ESRD, by of ESRD, by diagnosisdiagnosisFig 1.14 (Volume 2)Fig 1.14 (Volume 2)

December 31 point prevalent ESRD patients. Adj: age/gender/race; ref: 2005 ESRD patients.


Causes of Renal Causes of Renal FailureFailure DM 30-40%DM 30-40% HTN 25-35%HTN 25-35% GNGN GeneticGenetic

– Polycystic Kidney DiseasePolycystic Kidney Disease– Alport’sAlport’s

Obstructive nephropathyObstructive nephropathy Drug-inducedDrug-induced UnknownUnknown


Adjusted all-cause mortality Adjusted all-cause mortality in the ESRD & general in the ESRD & general populations, by age, 2009 populations, by age, 2009 Fig 5.2 (Vol 2)Fig 5.2 (Vol 2)

Prevalent ESRD & general Medicare (non-ESRD) patients. Adj: gender/race; ref: Medicare patients, 2009.


FIGURE 17-15 Causes of death among U.S. transplant recipients with a functioning graft. CVD, cardiovascular disease. (From U.S. Renal Data System: USRDS 2005 Annual Data Report: Atlas of End-Stage Renal Disease in the United States. Bethesda, MD, National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, 2005, p 152.)

Overview of Dialysis Overview of Dialysis TherapyTherapy Outpatient (in-center) Hemodialysis (HD) – Outpatient (in-center) Hemodialysis (HD) –

usually done 3 times a week. Most common usually done 3 times a week. Most common type.type.

Home therapies:Home therapies:– Daily or nocturnal HD.Daily or nocturnal HD.– Chronic Ambulatory Peritoneal Dialysis (CAPD)Chronic Ambulatory Peritoneal Dialysis (CAPD)– Cyclic Peritoneal Dialysis usually performed at Cyclic Peritoneal Dialysis usually performed at

night.night.– Require patient or caregiver be thoroughly trained Require patient or caregiver be thoroughly trained

to perform independently.to perform independently.– Less common as in-center hemodialysis. Less common as in-center hemodialysis.

Renal Replacement Renal Replacement TherapyTherapy

NIDDK

Renal TransplantationRenal Transplantation

Treatment, not cure.Treatment, not cure. Usually performed Usually performed

w/o nephrectomy.w/o nephrectomy. Requires lifelong Requires lifelong

immunosuppression.immunosuppression. Immunos may cause Immunos may cause

side effects (DM, side effects (DM, HTN, hyperlipidemia, HTN, hyperlipidemia, CVD, cancer, CVD, cancer, infection).infection).

NIDDK

Complications of Renal Complications of Renal Failure (partial)Failure (partial) Intradialytic Hypotension (during HD)Intradialytic Hypotension (during HD) MalnutritionMalnutrition GI BleedGI Bleed Nephrogenic Systemic FibrosisNephrogenic Systemic Fibrosis NeurologicNeurologic Cardiovascular disease (CVD)Cardiovascular disease (CVD) InfectionInfection Acquired Cystic DiseaseAcquired Cystic Disease AnemiaAnemia

Hypotension Hypotension Occurs in 20-30 % of HD Occurs in 20-30 % of HD treatmentstreatmentsCauses:Causes: Rapid reduction of plasma osmolality causing Rapid reduction of plasma osmolality causing

extracellular water to shift into cells.extracellular water to shift into cells. Rapid fluid removal/ultrafiltration (UF) of>1.5 L/hr.Rapid fluid removal/ultrafiltration (UF) of>1.5 L/hr. Poor cardiac reserve.Poor cardiac reserve. Autonomic neuropathy.Autonomic neuropathy. BP meds.BP meds. Eating before or during dialysis.Eating before or during dialysis. May present 1-2 hours post-treatment.May present 1-2 hours post-treatment.Therapies- Volume replacement, adjust meds, UF Therapies- Volume replacement, adjust meds, UF

slowly, check EF.slowly, check EF.

HypertensionHypertension

Seen in 85% of renal patients.Seen in 85% of renal patients. Salt/water excess usual cause.Salt/water excess usual cause. Elevated renin secretion from Elevated renin secretion from

diseased kidneys is common.diseased kidneys is common.

HypertensionHypertension

ESA side effectESA side effect Sympathetic over activity.Sympathetic over activity. Non-compliance with meds or Non-compliance with meds or

withholding prior to dialysis.withholding prior to dialysis. Salt and water restriction not Salt and water restriction not

followed.followed.

MalnutritionMalnutritionAssociated with decreased Associated with decreased survivalsurvivalCauses:Causes: Drug effects.Drug effects. Chronic constipation.Chronic constipation. Lack of understanding of renal nutrition.Lack of understanding of renal nutrition. Low income.Low income. Malabsorption and GI motility disorders.Malabsorption and GI motility disorders. Impaired taste.Impaired taste.All Patients are evaluated and followed by All Patients are evaluated and followed by

dietician in dialysis unit. CKD patients dietician in dialysis unit. CKD patients should receive dietary education as part of should receive dietary education as part of CKD care.CKD care.

GI BleedGI Bleed

Don’t assume anemia is simply from CKD. Don’t assume anemia is simply from CKD. Check iron levels and w/u when deficient.Check iron levels and w/u when deficient.

Gastritis - most common.Gastritis - most common. Angiodysplasia - second most common.Angiodysplasia - second most common. Uremic platelet dysfunction contributes to Uremic platelet dysfunction contributes to

the severity- DDAVP can help short-term.the severity- DDAVP can help short-term. If patient is possible transplant candidate, If patient is possible transplant candidate,

use WBC filter with PRBC transfusions use WBC filter with PRBC transfusions when blood products needed… when blood products needed…

decreases HLA antibody formation.decreases HLA antibody formation.

Nephrogenic Systemic Nephrogenic Systemic FibrosisFibrosis

Typically starts with patients Typically starts with patients reporting swelling and a reporting swelling and a “tight” feeling in extremities.“tight” feeling in extremities.

Skin changes may be red or Skin changes may be red or dark patches, papules, dark patches, papules, plaques, or nodules.plaques, or nodules.

Progressing over days to Progressing over days to weeks to inhibit flexion and weeks to inhibit flexion and contraction of joints & contraction of joints & contractures.contractures.

Skin becomes “woody” with Skin becomes “woody” with peu d’orange consistencypeu d’orange consistency

Lesions often symmetrical, Lesions often symmetrical, involving LE first, then UE.involving LE first, then UE.

Most common with GFR < 30 Most common with GFR < 30 and Gadolinium exposure.and Gadolinium exposure.

From Cowper NFD/NSF Website.

Nephrogenic Systemic Nephrogenic Systemic FibrosisFibrosis

Soft tissue swelling & contracturesRaised and erythematous nodular plaques, & linear and confluent regions of fibrosis

From nephrogenic-systemic-fibrosis.info

Neurologic Neurologic Complications of Complications of UremiaUremia Uremic neuropathy is the most common Uremic neuropathy is the most common

neurologic finding.neurologic finding. Uremic encephalopathy (UE) develops when Uremic encephalopathy (UE) develops when

GFR < 10% of normal. GFR < 10% of normal. – Rare in well dialyzed patients.Rare in well dialyzed patients.– Seizures are seen in 25% of patients with UE.Seizures are seen in 25% of patients with UE.

Restless legs syndrome is reported in > 40% Restless legs syndrome is reported in > 40% of uremic patients.of uremic patients.

Myopathy, optic neuropathy and Myopathy, optic neuropathy and mononeuropathies noted.mononeuropathies noted.

Hyperkalemia can cause flaccid quadriparesis.Hyperkalemia can cause flaccid quadriparesis.

Goetz: Textbook of Clinical Neurology, 3rd ed

Neurologic Neurologic Complications of Complications of Uremia (cont.)Uremia (cont.)

Vestibulocochlear and Vestibulocochlear and neuromuscular junction neuromuscular junction disturbances can be seen in disturbances can be seen in association with aminoglycoside association with aminoglycoside atb.atb.

Loop diuretics can cause tinnitus.Loop diuretics can cause tinnitus. Amyloid fibrils (Amyloid fibrils (2 microglobulin 2 microglobulin

deposits) can cause carpal tunnel deposits) can cause carpal tunnel syndrome.syndrome.Goetz: Textbook of Clinical Neurology, 3rd ed


Subdural hemorrhage.Subdural hemorrhage. Dialysis headaches.Dialysis headaches. Exacerbation of migraine Exacerbation of migraine

headaches.headaches. Ischemic monomelic Ischemic monomelic

neuropathy.neuropathy.



Dysequilibrium Syndrome Dysequilibrium Syndrome – Cerebral edema d/t rapid reduction Cerebral edema d/t rapid reduction

of omolality during hemodialysis.of omolality during hemodialysis. Dialysis dementia (vascular, Dialysis dementia (vascular, 2-2-

macroglobulin).macroglobulin).



Vitamin deficiencyVitamin deficiency– Water soluble vitamins dialyzed out.Water soluble vitamins dialyzed out.– Poor nutrition common.Poor nutrition common.– Nephrology vitamins available.Nephrology vitamins available.



Phenytoin has decreased plasma Phenytoin has decreased plasma binding and higher free (active) binding and higher free (active) drug. drug. – Check free phenytoin level.Check free phenytoin level.– Usually the same loading and Usually the same loading and

maintenance dosed used.maintenance dosed used.– Since half-life decreased, TID dosing Since half-life decreased, TID dosing

regimen is favored over BID.regimen is favored over BID.


Syncope in Renal Syncope in Renal DiseaseDisease ArrhythmiasArrhythmias

– IntrinsicIntrinsic– Electrolyte induced (K, Calcium, Mg.)Electrolyte induced (K, Calcium, Mg.)– Acidemia, or rarely alkalemia.Acidemia, or rarely alkalemia.

Intra- or post-dialytic hypotension.Intra- or post-dialytic hypotension. Common causes occur commonly.Common causes occur commonly.

– Given CVD risk, need thorough Given CVD risk, need thorough evaluation for vascular disease.evaluation for vascular disease.

Barbour et al. Semin Nephrol 2001; 21 (1) : 66-78.

CVD and CKDCVD and CKD

Primary cause of death is accelerated CVDPrimary cause of death is accelerated CVD AHA: ESRD should be considered highest AHA: ESRD should be considered highest

risk.risk.1 1 Considered a CV risk equivalent. Considered a CV risk equivalent. Entire spectrum of CKD associated with Entire spectrum of CKD associated with

increased risk. increased risk. 2-42-4

– Very high prevalence of traditional CKD risks.Very high prevalence of traditional CKD risks.– HTN & cholesterol have U-shaped relationship.HTN & cholesterol have U-shaped relationship.

1. Sarnak et al. Circulation 2003; 108: 2154-2169.2. Collins et al. Kidney Int suppl 2003. S24-S31.3. Henry et al. Kidney Int 2002; 62:1402-1407.4. Muntner et al. J Am Soc Nephrol 2002; 13:745-753

DyslipidemiaDyslipidemia

Lipids combine with apolipoproteins to Lipids combine with apolipoproteins to form lipoproteins.form lipoproteins.

Lipoprotein profiles are affected by CKDLipoprotein profiles are affected by CKD– HDL, LDL and total cholesterol decline with HDL, LDL and total cholesterol decline with

worsening renal function.worsening renal function.11

– Dense LDL and lipoprotein (a) are Dense LDL and lipoprotein (a) are increased. increased. 22

– Elevated lipoprotein(a) is an independent Elevated lipoprotein(a) is an independent risk factor for CVD in hemodialysis patients risk factor for CVD in hemodialysis patients and is associated with vascular events. and is associated with vascular events. 33

1. Kanske BL. Am. J Kidney Dis, 1988; 32 (suppl 3) : S142-56.2. Kwan et al. J. Am. Soc Nephrol 2007; 18 (4) : 1246-61.3. Cressman et al. Circulation 1992; 86 (2) : 475-82.

CV MortalityCV Mortality

Foley et al. Am J Kidney Dis 32 (suppl):S112–S115, 1998 Brenner and Rector's The Kidney, 8th ed.

CVD in patients with or CVD in patients with or

without CKD, 2009without CKD, 2009 fig 4.1 (Vol 1)fig 4.1 (Vol 1)

December 31 point prevalent Medicare enrollees age 66 & older, with fee-for-service coverage for all of 2009.


Effects of CKD on Effects of CKD on Cardiovascular SystemCardiovascular System

McCullough PA: Why is chronic kidney disease the “spoiler” for cardiovascular outcomes? J Am Coll Cardiol 41;725, 2003

Non-Traditional CVD Non-Traditional CVD Risk Factors in Renal Risk Factors in Renal DiseaseDisease AlbuminuriaAlbuminuria MalnutritionMalnutrition HyperhomocysteineHyperhomocysteine

miamia Elevated Lp(a)Elevated Lp(a) Low GFRLow GFR AnemiaAnemia InflammationInflammation ECF overloadECF overload

Endothelial Endothelial dysfunctiondysfunction

Metabolic syndromeMetabolic syndrome Abnormal Ca/PO4 Abnormal Ca/PO4

metabolismmetabolism HyperparathyroidisHyperparathyroidis

mm

Dyslipidemia (cont.)Dyslipidemia (cont.)

Triglycerides tend to increase Triglycerides tend to increase with CKD, especially NS and those with CKD, especially NS and those on dialysis.on dialysis.11

NFK recommends lifestyle NFK recommends lifestyle modifications for those with CKD.modifications for those with CKD.

Target LDLC is < 100 mg/dl for Target LDLC is < 100 mg/dl for allall renal patients. renal patients.

1. Kwan et al. J. Am. Soc Nephrol 2007; 18 (4) : 1246-61.

Dyspnea in ESRDDyspnea in ESRD Pulmonary edema, often non-cardiogenic.Pulmonary edema, often non-cardiogenic.

– Failure to decrease est dry weight (EDW) in those Failure to decrease est dry weight (EDW) in those losing weight.losing weight.

– Excess intake, exceeding capacity for UF.Excess intake, exceeding capacity for UF.– Peritoneal dialysate leakage.Peritoneal dialysate leakage.

High output cardiac failure can develop from AV grafts High output cardiac failure can develop from AV grafts or fistulae which can have blood flow of >20-30% of or fistulae which can have blood flow of >20-30% of cardiac output .cardiac output .

Pneumothorax or hemothorax after catheter placement.Pneumothorax or hemothorax after catheter placement. Pericardial effusion or cardiac tamponade.Pericardial effusion or cardiac tamponade.

Initial Rx of Pulmonary Initial Rx of Pulmonary Edema in Renal FailureEdema in Renal Failure Supplemental oxygen.Supplemental oxygen. Morphine.Morphine. High dose loop Diuretic (High dose loop Diuretic (ifif significant significant

residual UO).residual UO).– May work as vasodilator.May work as vasodilator.

Preload reduction with nitrates.Preload reduction with nitrates. Rx of HTN.Rx of HTN. Definitive rx is fluid & salt removal Definitive rx is fluid & salt removal

with dialysis- not always “urgent.”with dialysis- not always “urgent.”

Chest Pain in CKDChest Pain in CKD

50% of renal deaths are related to ischemic 50% of renal deaths are related to ischemic heart disease, so ACS has to be in Ddx.heart disease, so ACS has to be in Ddx.

Baseline EKG often abnormal d/t LVH, e-lyte Baseline EKG often abnormal d/t LVH, e-lyte disturbances or fluid overload.disturbances or fluid overload.

ST segment elevation is indicative of ACS.ST segment elevation is indicative of ACS.11

Chronic troponin elevations are misleading.Chronic troponin elevations are misleading. Uremic PericarditisUremic Pericarditis Pulmonary embolus, 12.5% incidence in Pulmonary embolus, 12.5% incidence in

ESRD vs 22% in general population.ESRD vs 22% in general population.22

1. Goldsmith et al, Kidney Int 2001; 60 : 2059-78.2. Wiesholder et al, Am J Kidney Dis 1999; 33:702-8.

Chest Pain in Renal Disease Chest Pain in Renal Disease (cont)(cont)

Higher prevalence of silent Higher prevalence of silent ischemia.ischemia.

Patient with CKD presenting with Patient with CKD presenting with chest chest discomfort has 40% discomfort has 40% cardiac event cardiac event rate @ 30 rate @ 30 days.days.11

ESRD patients have highest ESRD patients have highest mortality mortality after AMI. after AMI. 22

1. McCullough et al: Arch Intern Med 2002; 162:2464.2. Braumwald

Approach to ESRD Approach to ESRD patient with Suspicion patient with Suspicion of CADof CAD

McCullough PA: Kidney Int Suppl 95:s51-58, 2005

Long-term survival by CAD Long-term survival by CAD management strategy in management strategy in patients with CKD or ESRD. patients with CKD or ESRD.

Keely et al. Am J Cardiol 92:509-514, 2003

Management of CVD Management of CVD in Renal Failurein Renal Failure Lifestyle modification, as per general Lifestyle modification, as per general

population.population.– Including physical activity when possibleIncluding physical activity when possible..

Control BP.Control BP. Goal LDL < 100Goal LDL < 100. . JNC7 recognizes CKD as JNC7 recognizes CKD as

independent risk factorindependent risk factor Have low threshold to evaluate atypical Have low threshold to evaluate atypical

findings:findings:– Worsening fatigue.Worsening fatigue.– Hypotension in someone with hx HTN.Hypotension in someone with hx HTN.– Atypical chest discomfort.Atypical chest discomfort.– Dyspnea not related to pulmonary edema.Dyspnea not related to pulmonary edema.

Calcification & Calcification & vasculaturevasculature

Calcifications of the pelvic arteries.Calcifications of the pelvic arteries.London GM, et al. Arterial media calcification in end-stage London GM, et al. Arterial media calcification in end-stage

renal disease: impact on all-cause and cardiovascular renal disease: impact on all-cause and cardiovascular mortality. mortality. Nephrol Dial TransplantNephrol Dial Transplant. 2003;18(9):1731-. 2003;18(9):1731-1740, by permission of Oxford University Press .1740, by permission of Oxford University Press .

Infections and Renal Infections and Renal DiseaseDisease

Renal failure = immunocompromised Renal failure = immunocompromised state.state.

Hypothermia common in renal failure.Hypothermia common in renal failure.– Fever often absent.Fever often absent.– Low grade temps can indicate serious Low grade temps can indicate serious

infection.infection. Catheters and grafts are often source.Catheters and grafts are often source. Higher incidence of HCV.Higher incidence of HCV. Note many antibiotics are dialyzable and Note many antibiotics are dialyzable and

require require dose adjustment .dose adjustment .

Fatal Bacterial InfectionsFatal Bacterial Infections in HD & PD in HD & PD

in Australia and New Zealand 1995-in Australia and New Zealand 1995-

20052005

Johnson et al. AM J Kidney Dis 53:290-297.

Acquired Renal Cystic Acquired Renal Cystic Disease (ARCD)Disease (ARCD) Renal neoplasms seen in 10% of chronic Renal neoplasms seen in 10% of chronic

HD HD patients. Adenomas most common.patients. Adenomas most common. With ARCD, prevalent incidence is 20-With ARCD, prevalent incidence is 20-

25%.25%. Present silently or w flank pain and Present silently or w flank pain and

hematuria.hematuria. RCC has 3-7X higher incidence in ESRD RCC has 3-7X higher incidence in ESRD

than than general population.general population. ARCD may regress post-tx.ARCD may regress post-tx.

Wein: Campbell-Walsh Urology, 9th ed.

Acquired Renal Cystic Acquired Renal Cystic Disease (ARCD)Disease (ARCD)

Wein: Campbell-Walsh Urology, 9th ed.

Secondary Hyper-Secondary Hyper-parathyroidism (SPTH)parathyroidism (SPTH) CKD is the most common cause of SPTH.CKD is the most common cause of SPTH.

– Failing kidneys do not convert enough vitD to Failing kidneys do not convert enough vitD to its active form.its active form.

– Failing kidneys inadequately excrete Failing kidneys inadequately excrete phosphorus. This results in (insoluble) ca-phosphorus. This results in (insoluble) ca-phos complexes that remove calcium from phos complexes that remove calcium from the circulation. the circulation.

Both processes leads to hypocalcemia & Both processes leads to hypocalcemia & secondary hyperparathyroidism. secondary hyperparathyroidism.

Vascular calcification common.Vascular calcification common.

Rx Secondary Rx Secondary HyperparathyroidismHyperparathyroidism Low phos diet and phos binders.Low phos diet and phos binders. Active Vit D supplements calcitriol Active Vit D supplements calcitriol

(Rocaltrol), doxercalciferol (Rocaltrol), doxercalciferol (Hectorol), paricalcitol (Zemplar) (Hectorol), paricalcitol (Zemplar)

Calcimimetic- cinacalcet (Sensipar) Calcimimetic- cinacalcet (Sensipar) mimics the action of calcium on mimics the action of calcium on tissues by allosteric activation of tissues by allosteric activation of ca-sensing receptor.ca-sensing receptor.

Educate and reinforce, re-educate.Educate and reinforce, re-educate.

SummarySummary

Renal failure is a systemic disease that Renal failure is a systemic disease that affects every other organ system.affects every other organ system.

For any age, CKD and ESRD patients For any age, CKD and ESRD patients have markedly increased mortality have markedly increased mortality compared to general population.compared to general population.

CVD has very high incidence and CVD has very high incidence and needs to be looked for and treated needs to be looked for and treated aggressively.aggressively.

Vague presentations of infection or Vague presentations of infection or CVD are common.CVD are common.

Questions?Questions?

[email protected]@ochsner.org

Chronic Kidney Disease (CKD) in the Hospitalized Patient Catherine Staffeld-Coit, MD.

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Transcript of Chronic Kidney Disease (CKD) in the Hospitalized Patient Catherine Staffeld-Coit, MD.