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Chronic Kidney Disease Detection, Prevention and Pharmacologic Management Michelle Shields, RN, MSN, CRNP Renal and Electrolyte Associates, Inc. November 7, 2014

The Prevalence of CKD in the General Population > 90 Stage 1 5.9M 60–89 Stage 2

5.3M

30–59 Stage 3

7.6M

0.4M

15–29 Stage 4

0.3M

< 15 Stage 5

Levey et al. Ann Intern Med. 2003;139:137-147.

26 Million CKD Patients X > 90 Stage 1 5.9M 60–89 Stage 2

5.3M

30–59 Stage 3

7.6M

CKD Incidence 1 in 9 Adults 3 times that of cancer 600 times that of AIDS

0.4M 0.3M

15–29 Stage 4 < 15 Stage 5

Coresh et al: JAMA Nov 7, 07; 298(17):2038-2047.

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Expected Remaining Lifetimes (Years) Years

35

End-stage renal disease

General population

30 25

28.6

20 20.4

15 10 5

6.0

4.4

0

60-64

50-54

Age US Renal Data System (USRDS) 2006 Annual Data Report: Atlas of End-Stage Renal Disease in the United States, National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD, 2006.

Life expectancy of NHANES participants with or without CKD, 1999–2004 Figure 1.16 (Volume 1)

USRDS, 2014 report

Cardiovascular Disease (CVD) Mortality General Population versus ESRD Patients Annual CVD mortality (%)

100 10 1 0.1 GP male GP female GP black GP white

0.01

Dialysis male Dialysis female Dialysis black Dialysis white

0.001 25-34

35-44

45-54

55-64

65-74

75-84

>85

Age (years) GP=General Population ESRD=End-Stage Renal Disease

Foley RN, Parfrey PS, Sarnak MJ. Am J Kidney Dis. 1998;32(suppl):S112-S119.

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Annual Medicare Cost Per Patient ($)

Medicare costs are 2.7 times greater for CKD patients than for non-CKD patients $70,000

$62,676

$60,000 $50,000 $40,000 $30,000 $16,476

$20,000 $6,060

$10,000 $0

Non-CKD

CKD

Dialysis

Based on data from USRDS 2002; costs based on diagnostic codes obtained from billing data; patients> 67 years of age Hunsicker LG. J Am Soc Nephrol . 2004;15:1363-1374

Point prevalent distribution & annual costs of Medicare (fee-for-service) patients, age 65 & older, with diagnosed diabetes, CHF, & CKD, 2011 Figure 7.1 (Volume 1)

USRDS, 2014

Risk of hospitalization, CV events, and death increases as GFR declines

140 120 86.75

100 80 45.26

60 40 20 0

13.54 17.22

60 45-59 30-44 15-29 =1 protein obtain protein-creatinine ratio  

If ratio is < 200mg/g recheck at periodic health evaluation If ratio is > 200mg/g Diagnostic evaluation

Early Recognition of Kidney Disease  

Identifying those at risk Screening: creatinine and proteinuria

 Detection 

of Kidney Disease

Staging of Chronic Kidney Disease

Estimate Kidney Function  



Looking at creatinine alone is inaccurate Inulin clearance is gold standard measurement of glomerular filtration rate (GFR), but not practical Estimates of kidney function are the best indices for the level of kidney function.   

Cockcroft-Gault Equation Abbreviated MDRD(The Modification of Diet in Renal Disease) CKD-EPI (Chronic Kidney Disease epidemiology Consortium)

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Stages of CKD

NKF k/DOQI Clinical Practice Guidelines for CKD, 2005

Case Study 

 

 

70 yo woman comes to ER with complaints of lethargy, fatigue, and recent fall. PMH: DM type 1, HTN Recent shingles outbreak started on acyclovir 800 mg every 4 hours. Creatinine in ER 1.5, Renal dosing of acyclovir, q 12 hours.

Estimate of GFR  Creatinine

1.5

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MDRD Estimated Creatinine Clearance Age

Sex

Race

Creat

20 yo

Male

AA

1.5

60 yo

Male

AA

1.5

40 yo

Female

White 1.5

70 yo

Female

White 1.5

eGFR

MDRD Estimated Creatinine Clearance Age

Sex

Race

Creat

20 yo

Male

AA

1.5

60 yo

Male

AA

1.5

40 yo

Female

White 1.5

70 yo

Female

White 1.5

eGFR 77 ml/min

MDRD Estimated Creatinine Clearance Age

Sex

20 yo

Male

60 yo 40 yo 70 yo

Race

Creat

eGFR

AA

1.5

77 ml/min

Male

AA

1.5

61 ml/min

Female

White 1.5

Female

White 1.5

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MDRD Estimated Creatinine Clearance Age

Sex

Race

Creat

eGFR

20 yo

Male

AA

1.5

77 ml/min

60 yo

Male

AA

1.5

61 ml/min

40 yo

Female

White 1.5

41 ml/min

70 yo

Female

White 1.5

MDRD Estimated Creatinine Clearance Age

Sex

Race

Creat

eGFR

20 yo

Male

AA

1.5

77 ml/min

60 yo

Male

AA

1.5

61 ml/min

40 yo

Female

White 1.5

41 ml/min

70 yo

Female

White 1.5

36 ml/min

Slow Progression of Kidney Disease 

Identify reversible causes  

  

ACE-I, ARB Avoid volume depletion Avoid nephrotoxic agents    

 

Decreased renal perfusion: hypovolemia, hypotension Urinary tract obstruction or infection

IV Contrast Aminoglycosides, Amphotericin NSAIDS, COX 2 inhibitors Cyclosporin, Tacrolimus

Risk Factor Reduction Management of Co-morbid conditions

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Goals of Management in CKD      

Early recognition of kidney disease Early referral to nephrology Risk Factor Modification Early identification and management of co-morbid conditions. Early management of complications of CKD Empower patients through education to make informed decisions in regards to their disease process, ability to impact disease progression and dialysis modality choice

Risk Factor Modification    

Smoking Cessation Weight reduction Exercise and Nutrition Counseling Cardiovascular Risk Reduction LDL < 100mg/dL HDL > 40mg/dL  Triglycerides < 150  Stress testing for those at risk for CVD  

Risk Factor Modification    

Smoking Cessation Weight reduction Exercise and Nutrition Counseling Cardiovascular Risk Reduction LDL < 100mg/dL HDL > 40mg/dL  Triglycerides < 150  Stress testing for those at risk for CVD  

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Risk Factor Modification 

Cardiovascular Risk Reduction 

Evaluation of 10 year CV Risk

Stone et al. 2013 ACC/AHA blood cholesterol guidelines

Treatment for CV Risk

Stone et al. 2013 ACC/AHA blood cholesterol guidelines

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KDIGO Clinical Practice Guidelines for lipid management in CKD. 



Follow Recommended AHA treatment with a statin for adults aged 50> with eGFR < 60 ml/min Statins not recommended in the dialysis populations as the magnitude of any relative reduction in risk appears to be minimal in the dialysis population.  Higher doses of statins not safe on dialysis  Maintain current dose of statins when initiating dialysis  Lipid measurements not recommended. KDIGO, Kidney Disease: Improving Global outcomes. Kidney International (2014) 85, 1303-1309

When to refer to Nephrology?     

eGFR < 60 ml/min/1.73 m Multiple Risk Factors Heavy or Increasing proteinuria Uncontrolled hypertension Rapid progression or Acute Renal Failure 

Target decline in GFR < 4 ml/min/1.73 m per year

1

Early Nephrologist Referral Improves Outcomes Impact on mortality

Impact on serum chemistries at start of dialysis 80% Percentage of Patients

One Year Mortality Rate

40%

30%

20%

10%

60% 40% 20% 0%

0% Early

> 4 mos

Late

1-4 mos < 1 month

(Time Prior to Start of Dialysis)

HCO3 6.5mg/dL

 Early (> 3 months)

Ca 4 begin nutrition counseling, consider phosphate binder  

Calcium based Non-Calcium based

National Kidney Foundation (NKF). K/DOQI clinical practice guidelines for bone metabolism and disease in chronic kidney disease. Am J Kidney Dis 2003;42(4 Suppl 3):S1-S201

Elevated Serum Phosphorus Increases Mortality Risk Relative risk 2.2 of death* 2.0

n=40,538

1.8 1.6

Referent Range

1.4 1.2 1.0 0.08 0.00 9

Serum phosphorous concentration (mg/dL)

Block GA, Klassen PS, Lazarus JM, Ofsthun N, Lowrie EG, Chertow GM. J Am Soc Nephrol. 2004;15:2208-2218.

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Calcium Acetate (Phoslo)  



Dosage Form: 667mg Starting Dose: 1334mg qAC; titrate to Phosphorus < 6 Pharmacology: 

 

Mechanism of action: binds intestinal phosphate Metabolism: other Excretion: feces



Caution: Impairs absorption of many other medicationS Adverse Reaction:



Contraindication:





 

Hypercalcemia Renal calculi Hypercalcemia; Ca x Po4 product > 66

Sevelamer (Renvela)  



Dosage Form: 800mg Starting Dose: 800-1600mg qAC; titrate to Phosphorus < 6 Pharmacology: 

 

Mechanism of action: binds intestinal phosphate Metabolism: other Excretion: feces

 



Caution: hypophosphatemia Adverse Reaction: nausea, vomiting, abdominal pain, constipation, obstruction, impaction, ileus Contraindication:   

Intestinal Obstruction Severe Constipation Major GI tract surgery

Lanthanum (Fosrenol) 





Dosage Form: 250, 500, 750 or 1000mg Starting Dose: 750 1500mg qAC; Pharmacology: 

 

Mechanism of action: binds intestinal phosphate Metabolism: other Excretion: bile

Adverse Reaction: nausea, vomiting, abdominal pain, constipation, obstruction, Contraindication:  

Intestinal Obstruction Inflammatory bowel disease

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Sucroferric oxyhydroxide (Velphoro) 

 



Dose: 500mg, three times daily with meals. Must be chewed Pharmacology: 500mg iron binds intestinal phosphate. Adverse Reactions: GI 

N/V, constipation, diarrhea, black stools



Drug interactions: 



Cannot be used with levothyroxine or vitamin D. Caution use in patients with gastric bypass, gastric absorption issues, hepatic disorders, hemochromatosis

Patient Education in CKD Education begins in primary care Continues through referral to Nephrology  CKD Stage 1-3: CKD, risk factor reduction, comorbid disease management, CKD progression  CKD Stage 4-5: Complications of CKD, Signs/symptom management, Transplant, Dialysis Options Education, Fistula First/Vein preservation  Nurse Educator and staff nurses empower patient to make a difference in the progression of their CKD.  

How do Primary Care and Specialty Nurse Practitioners Impact Progression of CKD?       

Early recognition of kidney disease Early referral to nephrology Risk Factor Modification Early identification and management of co-morbid conditions. Early management of complications of CKD Treatment Options Empower patients through education to make informed decisions in regards to their disease process, ability to impact disease progression and dialysis modality choice

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Goals of Management in CKD      

Early recognition of kidney disease Risk Factor Modification Stage 1 Early identification and management of comorbid conditions.Stage 2 Early management of complications of CKD Early referral to nephrology Stage 3 Empower patients through education to make informed decisions in regards to their disease process, ability to impact disease progression and dialysis modality choice Stage 4 Stage 5

Questions?

29