chronic renal failure: what the primary … annual conference/saturday/primary care.pdfchronic...

CHRONIC RENAL FAILURE: WHAT THE PRIMARY CARE CAN OFFER

The annual conference of the Lebanese Society

of Family Medicine

October 2017

Dr Hiba AZAR

OUTLINE: A journey through CKD

Screening for CKD: The why, the who and the how

Slowing the progression of CKD

Management of complications of CKD: the anemia, the hyperkalemia and the CKD-MBD

Screening for CKD: The why

• CKD is a silent disease.

• CKD is a leading cause of mortality, primarily via in increase in cardiovascular mortality.

• Progression of CKD can be slowed.

Screening for CKD: The who

• Not for everybody

• Population at risk:

▪ Diabetes.

▪ Hypertension.

▪ Systemic diseases, autoimmune diseases.

▪ Family history of kidney disease.

▪ Certain ethnicities.

▪ Recurrent kidney stones and UTIs.

Screening for CKD: The who

Screening for CKD: The how

• DO NOT rely on creatinine alone. Always use calculators of eGFR, CKD-Epi or MDRD.


18 years old male.

Creatnine1.2 mg/dl

CKD EPI= 88 ml/min

85 years old lady

Creatinine1.2 mg/dl

CKD EPI= 41ml/min


• DO NOT ask for microalbuminuria alone in the urine spot


Microalbuminuria40 mg/dl

Microalbuminuria40 mg/dl

Creatininuria1,3 g/dl

Creatininuria0.3 g/dl

UAER= 30 mg/g UAER= 133 mg/g


• Creatinine for calculation of eGFR.

• UAER.

• General exam of the urine.

• Renal ultrasound.


Chronic kidney disease and cardiovascular risk:epidemiology, mechanisms, and prevention. Lancet 2013

Very strong correlation between CKD , microalbuminuria and CVD mortality.

CKD doubles the risk of heart failure.

Increase in the risk of stroke, atrial fibrillation, coronary heart disease, peripheral artery disease irrespective of age and ethnicity.


• In patients with mild to moderate CKD, the risk of cardiovascular mortality is much higher than the risk of reaching end stage kidney disease.

• Only in stage 4 CKD, the risk of end stage kidney disease surpasses the risk of CV mortality.

Chronic kidney disease and cardiovascular risk:epidemiology, mechanisms, and prevention. Lancet 2013


• Lifestyle modifications

• Therapeutic interventions

Slowing the progression of CKD- lifestyle modifications

Smoking cessation Decreases CV mortality in general population. Tobacco use is associated with progression of CKD. Cessation effect not documented

Dietary counseling: Na< 2g/day Enhances effect of ACEi and ARBs on the proteinuria reduction and decrease the progression of CKD

Dietary counseling: Protein intake 0.8 g/kg/day

Protein intake more than 1.3 g/kg/day should be avoided

Reduction of BMI to 25 kg/m2

Regular physical exercise, 30 min five times weekly

Associated with reduction of cardiovascular mortality of 13%

ACP clinical practice guidelines 2013

Slowing the progression of CKD-therapeutic interventions

BP reduction to < 140/90 mm Hg for CKD patients and lower if proteinuria

Adjust according to age, comorbidities, progression of CKD, tolerance

Use of RAAS inhibitors Reduction in albuminuria, positivelyaffects renal prognosis (beware SI, high K)

No room for associating ACEi and ARB

Glycemic control Aim for an HbA1c of 7 or less unlessadvanced CKD, comorbidities and high risk of hypoglycemia

Lipid control Statins. Decrease of CV risk, no cleareffect on renal progression. Adjust dose of fibrates.

Antiplatelet therapy No specific recommandations

Uric acid lowering treatment No specific guidelines if asymptomatic

ACP clinical practice guidelines 2013

Management of complications of CKD-The anemia

The incidence of anemia increases with

the severity of kidney disease


• Manifestations: fatigue, decreased tolerance to effort, cold intolerance, general malaise, irritability.

• Normocytic, normochromic anemia.

• Due to the decrease in EPO production by kidney.

• Iron deficiency is frequent: decreased oral intake, increased loss, decreased absorption, inflammation and increased demand with ESA therapy.

• Iron stores should be regularly checked and repleted in CKD patients, before starting and during treatment with EPO.


CKD w/o anemia

eGFR>45 ml/min

Once yearly

eGFR< 45 ml/min

Twice yearly

CKD/anemia w/o ESA

eGFR>45 ml/min

Twice yearly

eGFR< 45 ml/min

Every 3 Months

CKD/anemia with ESA

Every 2 to four weeks at initiation

Then every 3 months

Suggested scheme for monitoring for anemia by KDIGO

KDIGO guidelines Kidney International 2012


Guidelines for iron therapy in CKD patients


• KDIGO guidelines for the management of anemia

✓ESA should be started after repletion of iron stores if Hb level is lower than 10g/dl.

✓Aim for a Hb level between 11 and 12g/dl.

✓Hb should not increase by more than 1-1.5 g/dl every month.

✓Hb above 12 g/dl under ESA therapy is associated with increased risk of stroke and worsening hypertension

KDIGO guidelines Kidney International 2012

Management of complications of CKD-The hyperkalemia

• Hyperkalemia is a common clinical problem in CKD patients.

• Particularly in diabetics and with the use of RAAS inhibitors.

Kovesdy CP, Am J Med 128:1281–1287, 2015


Murray et al KI 2016


• Diet.

• Use of diuretics. Correct metabolic acidosis.

• Avoid use of other drugs affect K levels.

• Sodium polystyrene sulfonate: a lot of controversies about efficacy and safety. Mostly used in the acute setting. Contraindicated if ileus, postoperative setting, opioids... Risk of colonic necrosis


• Patiromer: recently approved by FDA for use in acute and chronic hyperkalemia. Nonabsorbal polymer that exchanges potassium for calcium. Decreases safely K by 0.5-1 Meq/l. GI side effects. Interaction with other medications... Effect of calcium load in CKD patients?

• Zirconium cyclosilicate: ZS 9. Exchanges K for Na and hydrogen. Decreases K by 0.5-1 mEg/l. SI: edema. Not yet approved by FDA.

Management of complications of CKD-The CKD-MBD

www.kdigo.org

CalciumPhosphorusPTHVitamin DFGF23

Renal osteodystrphyAdynamicbone diseaseosteomalacia


Prevalence of abnormal mineral metabolism in CKD

Levin et al KI 2007; 71:31-38


Dg of biochemical abnormalities


Dg bone disease


Dg of vascular calcifications


Management

Thank you for your attention

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