1. CHRONIC KIDNEY DISEASE FOR THE GENERAL INTERNIST Selma Durakovic & Parker Gregg

2. 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?

3. NEW PATIENT IN PCC DOES HE HAVE CHRONIC KIDNEY DISEASE?

4. Chronic Kidney Disease ≥ 3 months Renal Abnormalities – Functional - eGFR < 60 mL/min/1.73m 2 OR – Structural - Kidney damage (albuminuria, cystic changes, etc) - “Catch all category” for any renal abnormality It is not all about GFR!

5. Staging: CKD and GFR 60 30

6. Staging: CKD and Albuminuria 30 300

7. 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?

8. CKD Staging : Putting It All Together * 60 30 300

9. CKD – Primary Diagnoses

10. Prevalence? 73 Mil 31 Mil 26 Mil HTN DM CKD More US Adults have CKD than DM!

11. CKD Prevalence HTN DM 31 Mil U.S. Adults 44% due to DM 28% due to HTN

12. BACK TO OUR PATIENT WHAT WORKUP SHOULD BE DONE FOR NEWLY DIAGNOSED CKD?

13. 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?

14. Workup for every patient with newly diagnosed CKD baseline creatinine UA and ACR renal ultrasound What can you learn from the ultrasound?

15. “Medical Renal Disease” Normal Ultrasound Renal Parenchymal Disease Increased echogenicity “Normal” length 11-14 cm < 9 cm indicative of CKD Thin cortex

16. Dilated Calyces

17. Cysts and Masses

18. 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?

19. CategoryDifferential DiagnosisWorkup Pre-renal physiology Intrinsic renal vascular disease Glomerular diseases Intrinsic tubular and interstitial diseases Obstructive nephropathy Differential and Comprehensive Workup for CKD

20. CategoryDifferential DiagnosisWorkup Pre-renal physiology Heart failure, cirrhosisTTE, liver enzymes, liver US Intrinsic renal vascular disease Glomerular diseases Intrinsic tubular and interstitial diseases Obstructive nephropathy Differential and Comprehensive Workup for CKD

21. CategoryDifferential DiagnosisWorkup Pre-renal physiology Heart failure, cirrhosisTTE, 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

22. CategoryDifferential DiagnosisWorkup Pre-renal physiology Heart failure, cirrhosisTTE, 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

23. CategoryDifferential DiagnosisWorkup Pre-renal physiology Heart failure, cirrhosisTTE, 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 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 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

24. CategoryDifferential DiagnosisWorkup Pre-renal physiology Heart failure, cirrhosisTTE, 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

25. CategoryDifferential DiagnosisWorkup 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

26. BACK TO OUR PATIENT HOW DO YOU INTERPRET THIS ULTRASOUND? WHAT SEQUELAE OF CKD DO YOU WANT TO MONITOR?

27. 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?

28. CKD Sequelae – It’s as easy as ABC A – albuminuria, anemiaB – blood pressure, bone healthC – cholesterolD – diet/drug avoidanceE – electrolytes

29. 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

30. 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, PO 4, PTH – Follow calcium and PO 4 with each visit

31. Cholesterol So … who doesn’t get a statin? Age > 50 eGFR > 60 with CKD eGFR < 60 & not on HD Age 18-49 with CKD + ANY OF: CAD DM prior CVA 10 year risk for CAD > 10% Dialysis or Renal transplant? Treatment statin statin ± ezetimibe s tatin Don’t start it! Don’t stop it!

32. Diet/Drug Avoidance Diet – Low protein, Low salt Drugs – NSAIDs – Aminoglycosides – Cocaine/illicits – Tobacco

33. Electrolytes Hyperkalemia – Often severe when eGFR < 10 mL/min/1,73 m 2 -or- – Impaired K + metabolism (ACEi/ARB/NSAIDs) Hyperphosphatemia – Excretion of PO 4 drops as kidney function decreases – PTH is compensatory until ~ eGFR 30 mL/min/1,73 m 2

34. Chronic Kidney Disease (.ckd) Diagnosis: Stage: Nephrology: Anemia: Bones: Cholesterol: Diet: Electrolytes: Dialysis: Date, type, biopsy? ACR, eGFR Consult required Hct, Fe panel, on EPO? Ca, PO4, Vit D, PTH Don’t start/stop if on HD or transplant Low protein, low salt, nutrition consult K+, on kayexelate? Access, schedule, plan for transplant

35. BACK TO OUR PATIENT WOULD YOU REFER TO NEPHROLOGY?

36. 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?

37. 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.

38. When to Refer

39. Other Reasons to Refer Refer to nephrology Unclear etiology Hematuria (> 3 RBC/hpf) Hematuria (> 3 RBC/hpf) Rapid decline in eGFR Complications of CKD A: anemia B: bone/mineral disorders, resistant HTN E: electrolyte abnormalities

40. Take Home Points Know 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

41. Questions?

42. 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 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%20Gui deline%202013.pdf http://www.kdigo.org/clinical_practice_guidelines/Lipids/KDIGO%20Lipid%20Management%20Gui deline%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 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 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 http://annals.org/article.aspx?articleid=1757302&resultClick=3