Kidney Disease Workup – When to refer to Nephrologist
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Transcript of Kidney Disease Workup – When to refer to Nephrologist
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