‘CLINICAL PEARLS’: UPDATES IN - Island Health...

‘CLINICAL PEARLS’: UPDATES IN CHRONIC KIDNEY DISEASE

MANAGEMENT

Chronic Disease Management Forum

Feb. 3, 2010Gaylene Hargrove BSc MD FRCPC

THE QUIZ

The recommended target hemoglobin for patients with CKD treated with Aranesp or EPO is:

A. 100 – 110 g/L

B. 110 – 120 g/L

C. 120 – 130 g/L

D. 130 – 140 g/L

THE QUIZ

Special caution should be exercised when using Aranesp or EPO in the following patient groups:

A. Diagnosis of malignancy

B. Documented CVD

C. Uncontrolled HTN

D. All of the above

THE QUIZ

Your patient has a serum potassium of 5.8; the following measures are indicated:

A. Referral to a renal dietitianB. Stop ACEI or ARB indefinitelyC. Initiate KayexalateD. Initiate a loop diuretic (if not already

taking)E. A,C, and D are correct

THE QUIZ

Contraindications to peritoneal dialysis include the following:

A. Obesity

B. Cognitive dysfunction/dementia; spouse

competent/highly functional

C. Age > 80 y/o

D. Previous abdominal surgery

E. History of IBD, multiple surgeries,

adhesions, previous SBO

OBJECTIVES

Discuss recent clinical trials and review current guidelines for anemia management in CKD pts.

Discuss approach to management of hyperkalemia in CKD patients.

Review aspects of peritoneal dialysis: new program initiatives in VIHA.

ANEMIA MANAGEMENT IN CKD

Guiding principles: Significant anemia develops in patients with GFR < 40

mL/min, due to reduced erythropoietin production

Before recombinant EPO, patients required multiple PRBC transfusions to maintain Hgb

rEPO revolutionized patient care: improved QOL, reduced need for PRBC txn

Uncontrolled trials demonstrated improved CV outcomes, improved survival, and better QOL scores with Hgb >110 g/L

Therefore, we hypothesized that treating to normalize Hgb would improve outcomes even more……..


Trial to Reduce CV Events with Aranesp Therapy (TREAT); Pfeffer, M et al. NEJM 2009

Objective: To determine whether treatment of low hemoglobin with darbepoetin(Aranesp) would reduce the risk of death and CV events and renal events in pts with Type 2 DM, CKD, and anemia

4038 pts; median eGFR 33-34 mL/min, baseline Hgb 104-105 g/L; Aranesp vs placebo (‘rescue’ Tx for placebo pt if Hgb < 90)

Target Hgb in treatment grp was 130 g/L; median F/U 29 mos


TREAT trial, cont’d Results:

Treatment grp Hgb: 125 vs. 106 in placebo grp

No difference in death or nonfatal CV events between grps

No difference in death or ESRD

*Fatal/nonfatal stroke more likely in treatment grp (5.0% vs 2.6%, HR 1.92 P<0.0001)

Increased stroke risk not explained by higherSBP


CHOIR Trial (Correction of anemia with EPO alpha in CKD); Singh et al. NEJM 2006

Trial halted after 16 months due to higher than expected CV event rate in higher target Hgb grp; both grps received EPO (not placebo-controlled)

Targets were 135 g/L vs 113 g/L

HR of CV events for higher Hgb grp 1.34, P=0.03


Conclusions/Current Guidelines: Higher hemoglobin targets (greater than 130 g/L) in

pts with CKD treated with Aranesp or EPO are associated with a higher risk of CV events/stroke

Current recommended target hemoglobin:

110 – 120 g/L

NOT to exceed 130 g/L

Requires close monitoring (bloodwork q 1-3 mos)

Initiate ESA therapy when Hgb < 100 g/L

HYPERKALEMIA IN CKD PTS

ETIOLOGY (usually multi-factorial): Low eGFR (over 90% extracellular K+ excreted via

renal mechanisms)

Dietary indiscretion

Drugs (impair renal K+ excretion): NSAIDs/COX-2 inhibitors

Septra/Bactrim

ACEI/ARB

Spironolactone, Triamterene

Cyclosporine, Tacrolimus (Transplant pts)

Extracellular shift (acidosis, insulin deficiency, cell lysis)


Management/approach depends on severity:

Severe (6.5 or greater)

Advise pt to go to ER; needs monitored bed

ACUTE Tx: IV Calcium, IV insulin/glucose, Salbutamol neb,

IV NaHCO3, PO Kayexalate, IV Furosemide

Moderate (5.6 – 6.4)

Obtain ECG, rpt labs

Hold culprit drugs, provide dietary counselling

Give Kayexalate (30 gm daily for 3 days, then PRN)

Start loop diuretic, or increase dose


Management, cont’d

Mild (5.1 – 5.5)

Dietary counselling

Diuretic

Usually no need to hold ACEI/ARB

*Ask about NSAID use, potassium-containing herbal Tx, OTC meds/supplements (in all cases)


When to ‘bail’ on ACEI/ARB therapy? ‘Life-threatening’ episode of hyperkalemia

Pt unable to comply with dietary restrictions

Associated acute drop in eGFR (>30%)

Documented bilateral renal artery stenosis (>70%)

Despite best efforts (dietary restriction, diuretic, Kayexalate), serum K+ > 5.6 (consistently)

WHY DO PERITONEAL DIALYSIS?

PD is a ‘lifestyle’ choice:

Advantages:

Travel – limitless opportunities

Pts maintain independence, autonomy

Pts can maintain employment

No need for vascular access surgery

Disadvantages:

Pts should avoid swimming (esp. hot tubs)

Some pts (usually younger) may have body image issues

*NOTE: risk of peritonitis similar to risk of CVC-related bacteremia in hemodialysis pts

WHO SHOULD NOT DO PD?

Absolute Contraindications:

Severe dementia, no committed caregiver

Morbid obesity, poor residual renal function

Unstable mental health disorder/psychiatric issues

‘No fixed address’ (need space to store supplies)

Severe liver disease with ascites, previous peritonitis

Hx of IBD, multiple surgeries, adhesions

Severe lung disease/oxygen-dependent; COPD or pulmonary fibrosis

WHO SHOULD NOT DO PD?

Relative Contraindications:

Colostomy/Ileostomy/Urostomy (ileal conduit)

Severe visual impairment, no supports

Morbid obesity

Multiple previous abdominal surgeries, previous SBO due to adhesions

NEW PROGRAM INITIATIVES

NAVIGATOR PROJECT (2008) Background

Only 17% if all VIHA dialysis pts are on PD

Findings of local study indicated 50% of pts on dialysis ‘parachute’ in (precipitous start, no prior education re: dialysis modalities)

Once on HD, many pts never received any educationregarding peritoneal dialysis as an option

Therefore, we proposed to pursue a project aimed to provide adequate education related to all RRT modalities, to enable pts to make independent choices to achieve the optimal modality


BEDSIDE PD CATHETER INSERTION Background

For past 10-15 yrs, only means of insertion for VIHA pts was surgical, under GA

Increasingly longer wait times for OR (up to 6 mos) identified as a barrier to pts ending up on PD as modality of choice

Three programs in BC have performed Bedside PD Catheter Insertion for 20-30 yrs; provincial study found these centers have much shorter wait times (1-4 weeks), equivalent (or less) complication rates, and more pts on PD (25-40%)


BEDSIDE PD CATHETER INSERTION Spring-Summer 2009: Project nurse worked toward

establishing standards of practice, set up protocols/order sets, established procedure room, ordered equipment/supplies

Sept-Oct 2009: Nurses trained, Dr. Hargrove trained

First four patients undergo procedure Oct 1-2

Nine pts to date; ‘successful’ in 8

Complications (all considered minor): Pericatheter leak in 2

Bleeding in one – procedure aborted, pt admitted O/N


BEDSIDE PD CATHETER INSERTION Advantages:

No GA – done under local anesthesia No need for admission – d/c home 2-4 hrs post Faster recovery time; diminished pain

*Contraindications: Pt requires hernia repair Colostomy/ileosomy Severe liver disease Morbid obesity Unstable mental health disorder Multiple previous abdominal surgeries

*These pts require referral to surgeon

SUMMARY

ANEMIA MGMT IN CKD Current recommended target Hgb 110-120 g/L

Higher Hgb (>130 g/L) associated with adverse CV outcomes

HYPERKALEMIA In most cases, ACEI/ARB may be continued

Pts require dietary education, often a loop diuretic

PERITONEAL DIALYSIS An effective modality that may achieve better QOL

New initiatives: goal is to enable pts to pursue modality of choice, based on having received adequate education

‘CLINICAL PEARLS’: UPDATES IN - Island Health...

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