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
Slide 3
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)
Slide 4
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
Slide 5
ANATOMY Kidney Renal artery Cortex Medulla 1 million nephrons
each Renal pelvis Ureter
Benign Prostatic Hypertrophy Anatomy and physiology
Slide 8
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
Slide 9
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
Slide 10
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
Slide 11
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
Slide 12
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
Slide 13
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
Slide 14
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
Slide 15
STAGES OF CKD
Slide 16
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
Slide 17
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
Slide 20
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
Slide 21
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
Slide 22
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
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)
Slide 25
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
Slide 26
HYPERLIPIDEMIA Statin dosesGFR >/=30
Slide 27
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
Slide 28
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
Slide 29
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
Slide 30
PAIN MANAGEMENT Avoid All NSAIDS and Cox inhibitors Toradol
Darvocet, Demerol, and Codeine, Benadryl (Beers list), Cymbalta
avoid
Slide 31
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
Slide 32
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
Slide 33
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
Slide 34
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
Slide 35
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
Slide 36
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 !!
Slide 37
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