CLINICAL LEARNING DAY

NEPHROLOGY UPDATE

Arasu Gopinath, MD Nephrology Associates of Utah

• BP targets • Albuminuria

• Screening and monitoring • Intermountain data • iCentra • Metformin and Radiocontrast administration

Delaying CKD progression

9/10/2016 2

CKD classification and prognosis

9/10/2016 3

Management of CKD progression IHC CKD CPM

9/10/2016 4

CKD Patient Counts by Stage and Category as of August 2016

A1 A2 A3 Missing

Test Grand Total

Normal to Mildly

Increased

Moderately

Increased

Severely Increased

<30 30-300 >300

G1 Normal >90 284 3,842 596 225 4,947

G2 Mildly Decreased 60-89 1,865 6,721 1,000 1,748 11,334

G3a Mild to Moderately Decreased

45-59 4,221 7,526 598 9,545 21,890

G3b Moderately to Severely Decreased

30-44 3,843 7,729 708 5,890 18,170

G4 Severely Decreased 15-29 1,286 4,028 523 1,568 7,405

G5 Kidney Failure <15 291 2,265 285 562 3,403

Missing Test 65 507 78 428 1,078

Grand Total 11,855 32,618 3,788 19,966 68,227

INTERMOUNTAIN (and affiliates) data

9/10/2016 5

• BP control

Goal BP < 130/80, if patient has UACR more than 30 mg/g Goal BP < 140/90, if patient has UACR less than 30 mg/g

Delaying CKD progression

9/10/2016 6

Evidence supporting BP target

9/10/2016 7

©2016 by American Diabetes Association

Data from prospective clinical trials on nephropathy progression in relation to systolic BP

9/10/2016 8

Blood Pressure Control in CKD

[VALUE] n=22,987

[VALUE] n=24,498

[VALUE] n=2,103

[VALUE] n=2,391

0%

10%

20%

30%

40%

50%

60%

70%

80%

Jan-16 Aug-16

Percent of CKD Patients Whose Blood Pressure is in Recommended Range

CKD w/ACR ≤ 300: Target 140/90 CKD w/ACR > 300: Target 130/80

INTERMOUNTAIN (and affiliates) data 9/10/2016 9

[VALUE] n=17,562

[VALUE] n=18,723

[VALUE] n=1,471

[VALUE] n=1,712

0%

10%

20%

30%

40%

50%

60%

70%

80%

Jan-16 Aug-16

Percent of CKD Who Have Known Hypertension Whose Blood Pressure is in Recommended Range

CKD&HTN w/ACR ≤ 300: Target 140/90 CKD&HTN w/ACR > 300: Target 130/80

INTERMOUNTAIN (and affiliates) data 9/10/2016 10

• Albuminuria reduction

• ACEI or ARB in all adults with UACR > 300 mg/g • ACEI or ARB in diabetics with UACR > 30 mg/g

Delaying CKD progression

9/10/2016 11

Albuminuria in relation to the percentage of clinical visits in which blood pressure (BP) values were reduced to <140/90 mmHg or to <130/80 mmHg.

Guido Grassi et al. Dia Care 2016;39:S228-S233 ©2016 by American Diabetes Association

ONTARGET data

9/10/2016 12

INTERMOUNTAIN (and affiliates) data 9/10/2016 13

[VALUE] n=7,876

[VALUE] n=8,642

[VALUE] n=8,747

[VALUE] n=8,722

[VALUE] n=25,977

[VALUE] n=27,221

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Jan-16 Aug-16

CKD Patients Receiving Labs

CKD w/ACR ≥ 30: eGFR prior 12 months

CKD w/eGFR <60: ACR prior12 months

INTERMOUNTAIN (and affiliates) data 9/10/2016 14

CKD checklist

9/10/2016 15

iCentra

9/10/2016 16

iCentra

9/10/2016 17

iCentra

9/10/2016 18

iCentra

9/10/2016 19

Metformin and radiocontrast

• Background: – causes lactic acidosis (rare but life threatening) – risk is higher in AKI or CKD G5 – radiocontrast risks AKI (small but significant)

9/10/2016 20

ACR recommendations:

•Category I: If eGFR ≥30 and no AKI, continue Metformin. No need to check Creatinine following contrast. •Category II: If CKD G4 or G5 or AKI, and/or undergoing arterial catheter studies that might result in emboli (atheromatous or other) to the renal arteries, hold metformin during or prior to the procedure, and for 48 hours after, until Creatinine has been re-checked and found to be normal.

9/10/2016 21

FDA press release 4/8/2016

•Discontinue metformin at the time of or before an iodinated contrast imaging procedure in patients with an eGFR between 30 and 60 mL/minute/1.73 m2 ; in patients with a history of liver disease, alcoholism, or heart failure; or in patients who will be administered intra-arterial iodinated contrast. Reevaluate eGFR 48 hours after the imaging procedure; restart metformin if renal function is stable.

9/10/2016 22

Metformin and Radiocontrast in CKD

* iCentra advisories being created. * Will likely review eGFR level if available or prompt its estimation when a contrast study is ordered. * PCP’s responsibility to discontinue Metformin when eGFR is < 30 ml/min

9/10/2016 23

Questions 1. 48 yr old male with type 2 diabetes, hypertension and

dyslipidemia, is seen on routine follow up. His weight is stable. He smokes ½ ppd, does not drink and walks 3 miles every other day. He is on Metformin 1000 mg bid, Glimepiride 2 mg daily, Ramipril 10 mg daily, HCTZ 25 mg qd, and Atorvastatin 20 mg daily.

BMI 28, BP 128/74, ACR 320 mg/g, A1c 6.8. His ACR 4 months prior was 15 mg/g.

Which of the following might be the reason for his worsening albuminuria? a. BP 128/74 b. Smoking ½ pack a day of cigarettes c. HCTZ 25 mg qd d. Atorvastatin 20 mg daily

9/10/2016 24

Answer:

Which of the following might be the reason for his worsening albuminuria? a. BP 128/74 b. Smoking ½ pack a day of cigarettes c. HCTZ 25 mg qd d. Atorvastatin 20 mg daily

9/10/2016 25

Questions

2. Which of the following anti-hypertensives can worsen proteinuria?

1. Carvedilol 2. Amlodipine 3. Ramipril 4. Candesartan 5. Verapamil

9/10/2016 26

Answer:

2. Which of the following anti-hypertensives can worsen proteinuria?

1. Carvedilol 2. Amlodipine 3. Ramipril 4. Candesartan 5. Verapamil

9/10/2016 27

Questions

3. Which of the following is not an appropriate strategy to reduce proteinuria?

1. Losartan + Diltiazem 2. Lisinopril + HCTZ 3. Valsartan + Spironolactone 4. Lisinopril + Valsartan

9/10/2016 28

Questions

3. Which of the following is not an appropriate strategy to reduce proteinuria?

1. Losartan + Diltiazem 2. Lisinopril + HCTZ 3. Valsartan + Spironolactone 4. Lisinopril + Valsartan

9/10/2016 29

Summary

•Test regularly (monitor progression, complications and treatment) • Control BP

• < 140/90, if ACR < 30 • < 130/80 if ACR> 300 and perhaps 30-300 as well

• Prescribe ACEI/ ARB for ACR > 30 in Diabetics or ACR > 300 in others

9/10/2016 30

CKD Clinical Learning Day

9/10/2016 31