chronic kidney disease for the general internist
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CHRONIC KIDNEY DISEASE FOR THE GENERAL INTERNIST
Selma Durakovic & Parker Gregg
Learning Objectives
How do you diagnose CKD?
What is the basic workup of CKD in the primary care setting?
What do you monitor in your patients who have CKD?
When do you refer your patient to nephrology?
63 M, IMMIGRANT FROM ETHIOPIA (IN 2008)
8/2013 – Cr 1.3, eGFR 56, HbA1c 7.8% – LOST TO FOLLOW UP
PMH: DM 2 WITH RETINOPATHY, HTN, AND HLD
2/2014 – BP 148/95, Cr 1.4, eGFR 51
NEW PATIENT IN PCC
DOES HE HAVE CHRONIC KIDNEY DISEASE?
Chronic Kidney Disease≥ 3 months
Renal Abnormalities– Functional
- eGFR < 60 mL/min/1.73m2
OR
– Structural - Kidney damage (albuminuria, cystic
changes, etc)- “Catch all category” for any renal
abnormality
It is not all about GFR!
Staging: CKD and GFR
60
30
Staging: CKD and Albuminuria
30 300
Why is Albuminuria so Important?
Diagnosis Does the patient have albuminuria?
– YES: Think Diabetes OR Glomerular Disease– NO: HTN, cystic diseases, drug toxicites, TI disease, etc
Prognosis– Inversely related to prognosis
Management– Decrease the albuminuria and slow the progression of CKD
Can you diagnose CKD in a patient with a GFR of 95?
CKD Staging : Putting It All Together
*60
30
30 300
CKD – Primary Diagnoses
Prevalence?
73 Mil 31 Mil26 Mil
HTN DMCKDMore US Adults have CKD than DM!
CKD
Prevalence
HTN
DM
31 Mil U.S. Adults
44% due to DM28% due to HTN
63 M, IMMIGRANT FROM ETHIOPIA (IN 2008)
PMH – DM2 WITH RETINOPATHY, HTN, AND HLD, TODAY WITH NEWLY DIAGNOSED CKD.
HE WANTS TO KNOW WHY HE HAS KIDNEY DISEASE AND WHAT CAN BE DONE ABOUT IT.
BACK TO OUR PATIENT
WHAT WORKUP SHOULD BE DONE FOR NEWLY DIAGNOSED CKD?
Learning Objectives
How do you diagnose CKD?
What is the basic workup of CKD in the primary care setting?
What do you monitor in your patients who have CKD?
When do you refer your patient to nephrology?
Workup for every patient with newly diagnosed CKD
baseline creatinine UA and ACR renal
ultrasound
What can you learn from the ultrasound?
“Medical Renal Disease”
Normal Ultrasound Renal Parenchymal Disease
Increased echogenicity
“Normal” length 11-14 cm
< 9 cm indicative of CKD
Thin cortex
Dilated Calyces
Cysts and Masses
Workup for every patient with newly diagnosed CKD
baseline creatinine UA and ACR renal
ultrasound
What other workup do you do for newly diagnosed CKD?
Category Differential Diagnosis Workup
Pre-renal physiology
Intrinsic renal vascular disease
Glomerular diseases
Intrinsic tubular and interstitial diseases
Obstructive nephropathy
Differential and Comprehensive Workup for CKD
Category Differential Diagnosis Workup
Pre-renal physiology Heart failure, cirrhosis TTE, liver enzymes, liver US
Intrinsic renal vascular disease
Glomerular diseases
Intrinsic tubular and interstitial diseases
Obstructive nephropathy
Differential and Comprehensive Workup for CKD
Category Differential Diagnosis Workup
Pre-renal physiology Heart failure, cirrhosis TTE, liver enzymes, liver US
Intrinsic renal vascular disease
Hypertensive nephrosclerosis, RAS, renal artery dissection HTN, imaging as appropriate
Glomerular diseases
Intrinsic tubular and interstitial diseases
Obstructive nephropathy
Differential and Comprehensive Workup for CKD
Category Differential Diagnosis Workup
Pre-renal physiology Heart failure, cirrhosis TTE, liver enzymes, liver US
Intrinsic renal vascular disease
Hypertensive nephrosclerosis, RAS, renal artery dissection HTN, imaging as appropriate
Glomerular diseases
Nephrotic or nephritic pattern and the associated Ddx for each
HIV, HBV, HCV, A1c, anti-GBM antibodies, ANA, ANCA, complements
Intrinsic tubular and interstitial diseases
Obstructive nephropathy
Differential and Comprehensive Workup for CKD
Category Differential Diagnosis Workup
Pre-renal physiology Heart failure, cirrhosis TTE, liver enzymes, liver US
Intrinsic renal vascular disease
Hypertensive nephrosclerosis, RAS, renal artery dissection HTN, imaging as appropriate
Glomerular diseases
Nephrotic or nephritic pattern and the associated Ddx for each
HIV, HBV, HCV, A1c, anti-GBM antibodies, ANA, ANCA, complements
Intrinsic tubular and interstitial diseases
Myeloma cast nephropathy, PKD, nephrocalcinosis, sarcoid, Sjögren’s, NSAIDs
SPEP/UPEP with immunofixation, serum free light chains
Obstructive nephropathy
Differential and Comprehensive Workup for CKD
Multiple myeloma/paraproteinemias can cause CKD in several ways:- Glomerular: amyloid, IG deposition- Tubular: cast nephropathy, Fanconi’s
syndrome- Interstitial: plasma cell infiltration,
interstitial nephritis
The following patients are at increased risk for multiple myeloma:- Over 40 w/o other cause of CKD- Other manifestations of MM
- Hypercalcemia- Bone Pain- Radiographic lesions- Anemia >> CKD
Category Differential Diagnosis Workup
Pre-renal physiology Heart failure, cirrhosis TTE, liver enzymes, liver US
Intrinsic renal vascular disease
Hypertensive nephrosclerosis, RAS, renal artery dissection HTN, imaging as appropriate
Glomerular diseases
Nephrotic or nephritic pattern and the associated Ddx for each
HIV, HBV, HCV, A1c, anti-GBM antibodies, ANA, ANCA, complements
Intrinsic tubular and interstitial diseases
Myeloma cast nephropathy, PKD, nephrocalcinosis, sarcoid, Sjögren’s, NSAIDs
SPEP/UPEP with immunofixation, serum free light chains
Obstructive nephropathy
Prostatic disease, metastatic cancer, retroperitoneal fibrosis
Imaging and physical exam as appropriate
Differential and Comprehensive Workup for CKD
Category Differential Diagnosis Workup
Pre-renal physiology
Intrinsic renal vascular disease HTN
Glomerular diseases
Nephrotic or nephritic pattern and the associated Ddx for each
HIV, HBV, HCV, A1c
Intrinsic tubular and interstitial diseases
Myeloma cast nephropathy SPEP/UPEP with immunofixation, serum free light chains
Obstructive nephropathy
Differential and Comprehensive Workup for CKD
63 M, IMMIGRANT FROM ETHIOPIA (IN 2008)
LABS – Cr 1.8, ACR 500 mg/g, A1c 7.9% HIV, HBV, HCV NEGATIVE SPEP/UPEP NORMAL
RENAL US – BILAT 8 CM KIDNEYS, 1.2 CM ECHOGENIC CORTEX
BACK TO OUR PATIENT
HOW DO YOU INTERPRET THIS ULTRASOUND?WHAT SEQUELAE OF CKD DO YOU WANT TO MONITOR?
Learning Objectives
How do you diagnose CKD?
What is the basic workup of CKD in the primary care setting?
What do you monitor in your patients who have CKD?
When do you refer your patient to nephrology?
CKD Sequelae – It’s as easy as ABC
• A – albuminuria, anemia
• B – blood pressure, bone health
• C – cholesterol
• D – diet/drug avoidance
• E – electrolytes
Albuminuria, Anemia
Albuminuria– Monitor ACR based on patient’s stage• Yearly if ACR < 300• Q6 months if ACR > 300
Anemia– EPO deficiency -> normochromic, normocytic– First step: exclude non-renal causes– Fe supplementation– Refer to start EPO at Hb < 10 g/dL
Blood pressure, Bone health
Blood pressure– <130/80 for diabetics– <140/90 for non-diabetics– Treat as you would: ACE, thiazide
Bone health– Vit D, calcium, PO4, PTH
– Follow calcium and PO4 with each visit
CholesterolSo … who doesn’t get a statin?
Age > 50eGFR > 60 with CKD eGFR < 60 & not on HD
Age 18-49 with CKD + ANY OF:
CADDMprior CVA10 year risk for CAD > 10%
Dialysis or Renal transplant?
Treatmentstatinstatin ± ezetimibe
statinstatinstatinstatin
Don’t start it! Don’t stop it!
Diet/Drug Avoidance
Diet– Low protein, Low salt
Drugs– NSAIDs– Aminoglycosides– Cocaine/illicits– Tobacco
Electrolytes
Hyperkalemia– Often severe when eGFR < 10 mL/min/1,73 m2
-or- – Impaired K+ metabolism (ACEi/ARB/NSAIDs)
Hyperphosphatemia– Excretion of PO4 drops as kidney function decreases– PTH is compensatory until ~ eGFR 30 mL/min/1,73 m2
Chronic Kidney Disease (.ckd)Diagnosis:Stage:Nephrology:Anemia:Bones:Cholesterol:Diet:Electrolytes:Dialysis:
Date, type, biopsy?ACR, eGFRConsult requiredHct, Fe panel, on EPO?Ca, PO4, Vit D, PTH Don’t start/stop if on HD or transplantLow protein, low salt, nutrition consultK+, on kayexelate?Access, schedule, plan for transplant
63 M, IMMIGRANT FROM ETHIOPIA (IN 2008)
PMH – DM2 WITH RETINOPATHY, HTN, AND HLD
LABS – Cr 1.8, eGFR 45, ACR 500 mg/g, A1c 7.9% HIV, HBV, HCV NEGATIVE Hct 39, K 4.8, Phos 5.1
BACK TO OUR PATIENT
WOULD YOU REFER TO NEPHROLOGY?
Learning Objectives
How do you diagnose CKD?
What is the basic workup of CKD in the primary care setting?
What do you monitor in your patients who have CKD?
When do you refer your patient to nephrology?
Refer sooner rather than later!
Delayed nephrology referral (<3-6 months prior to initiation of
dialysis)
Increased mortality
Preferably patients will should be referred 1 year prior to needing dialysis to allow them time to
choose their option, have a fistula placed and allow that fistula to mature, and get dialysis teaching.
When to Refer
Other Reasons to Refer
Refer to nephrology
Unclear etiology
Hematuria (> 3 RBC/hpf)
Rapid decline in
eGFR
Complications of CKD
A: anemiaB: bone/mineral disorders, resistant HTNE: electrolyte abnormalities
Take Home PointsKnow how to stage CKD based on GFR (30-60)
and albuminuria (30-300)
Tailor your workup to your patient
Monitor the ABCs
Early referral saves lives
Questions?
Sources• Adam, Andy and Adrian K. Dixon. Grainger and Allison’s Diagnostic Radiology, Fifth Edition. Chapter 38:
The Genitourinary Tract; Techniques and Anatomy. 2008. Accessed electronically 5 Feb 2014.• Adam, Andy and Adrian K. Dixon. Grainger and Allison’s Diagnostic Radiology, Fifth Edition. Chapter 39:
Renal Parenchymal Disease, Including Renal Failure, Renovascular Disease and Transplantation. Accessed electronically 5 Feb 2014.
• Kidney Disease Improving Global Outcomes (KDIGO) Clinical Practice Guidelines. 2012. http://www.kdigo.org/clinical_practice_guidelines/pdf/CKD/KDIGO_2012_CKD_GL.pdf
• KDIGO Clinical Practice Guideline for Lipid Management in Chronic Kidney Disease. Nov 2013. http://www.kdigo.org/clinical_practice_guidelines/Lipids/KDIGO%20Lipid%20Management%20Guideline%202013.pdf
• National Kidney Foundation Kidney Disease Outcomes Quality Initiative (KDOQI) Clinical Practice Guidelines for Chronic Kidney Disease: Evaluation, Classification, and Stratification, section on Approach to Chronic Kidney Disease Using These Guidelines. 2002. http://www.kidney.org/professionals/kdoqi/guidelines_ckd/p9_approach.htm
• National Kidney Foundation KDOQI Clinical Practice Guidelines for Chronic Kidney Disease: Evaluation, Classification, and Stratification. 2002. http://www.kidney.org/professionals/kdoqi/pdf/ckd_evaluation_classification_stratification.pdf
• Screening, Monitoring, and Treatment of Stage 1 to 3 Chronic Kidney Disease: A Clinical Practice Guideline From the American College of Physicians. Annals of Internal Medicine 2013. http://annals.org/article.aspx?articleid=1757302&resultClick=3
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