Dine & Learn Roundtable CKD What to Expect Dr. Caroline Stigant - - PowerPoint PPT Presentation

Dine & Learn Roundtable CKD – What to Expect

• Dr. Caroline Stigant

April 30, 2019

4/25/2019 1

CHRONIC KIDNEY DISEASE - DEFINITION

• 1. Persistently* abnormal kidney function (ie. GFR < 60 mL/min) due to

intrinsic disease of the kidney(s)

• r
• 2. Normal function (ie. GFR > 60), but persistent* structural or functional

abnormality of the kidneys, with either

• pathological abnormalities
• markers of kidney damage (ie. proteinuria, hematuria)
• kidney transplant

examples: early PCKD, low-grade nephritis, well functioning kidney transplant

* Persistent = >3 months

‘CGA’ of Kidney Disease Screening Cause, GFR, and Albuminuria

all required for assessing risk of complications and future outcomes

Green: low risk; Yellow: moderately increased risk; Orange: high risk; Red: very high risk

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COMMON CAUSES OF THE SYNDROME OF CKD

• Hypertension
• Diabetes
• Ischemic / vascular
• Glomerular disease
• PCKD
• Drug-Induced
• Pyelonephritis
• Reflux

99% of the diagnoses,

• most often normal urinalysis
• usually low-grade albuminuria (except DM)

GFR DECLINES WITH AGE (Average – 1 to 2 mL/min/year)

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NEPHRONS ARE LOST WITH AGING, PROPORTIONAL TO GFR DECLINE

The Substantial Loss of Nephrons in Healthy Human Kidneys with Aging

Denic A et al. JASN 2017;28

Normal kidney

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Nephrosclerosis NATURAL HISTORY OF CKD

• Results vary between studies and according to diagnosis, in general:
• Non-proteinuric disease / general population: -1 mL/min GFR per year
• Diabetes (untreated): -5-10 mL/min/yr
• Diabetes (treated): 1-5 mL/min/yr\
• Non-diabetic proteinuria: up to 10+ mL/min/yr
• Often a different syndrome
• Nephritic (hematuria, proteinuria, edema, hypertension)
• Nephrotic (albuminuria 3+ grams daily, hypoalbuminemia, edema, hypercholesterolemia)
• ‘RPGN’ – Rapidly progressive glomerulonephritis – active urine sediment with marked loss of

kidney function over weeks to months

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WHAT TO DO IF ABNORMAL RESULT

• For patients with a new finding of an eGFR < 60 mL/min or urine

abnormality, determine stability of patient’s kidney status by:

• Repeating within week(s),
• and then in 3-6 months
• ALWAYS GET URINALYSIS AND URINE ACR
• Is this ‘just’ a hemodynamic change or is this a different renal syndrome
• Except if severely abnormal (GFR < 30)
• Assess, repeat sooner, &/or involve nephrologist
• ONE MEASUREMENT IS NOT ENOUGH

PLEASE ALWAYS ALWAYS ALWAYS CONSIDER REVERSIBLE FACTORS

• Intercurrent illness
• Volume depletion
• Medications
• NSAIDs, aminoglycosides, IV contrast dye, diuretics
• Obstruction
• Remember: small fluctuations are common and not

indicative of progression

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Identify patients in your practice at high risk for Chronic Kidney Disease

• Patients with hypertension
• Patients with diabetes mellitus
• Patients with atherosclerotic coronary,

cerebral or peripheral vascular disease

• Patients with heart failure
• Patients with unexplained anemia
• Patients with a family history of end stage renal disease
• High risk ethnicity

eGFR <30 eGFR 30-60 eGFR >60

Consider reversible factors:

• Medication
• Volume depletion
• Intercurrent illness
• Obstruction

Repeat tests (usually in 2 - 4 weeks) Individualized follow up and treatment

• ther renal abnormalities are present

eGFR <30 eGFR 30-60

Nephrology referral recommended Follow eGFR at 3 months then serially Assess for persistent significant proteinuria Implement risk reduction eGFR < 30

• r progressive decline in eGFR
• r persistent significant proteinuria
• r inability to attain treatment targets

Stable eGFR 30-60 and no significant proteinuria

Impact of Lifestyle Therapies on Blood Pressure in Hypertensive Adults

Intervention Intervention SBP/DBP

Reduce foods with added sodium

• 1800 mg/day* sodium

Hypertensive

• 5.1 / -2.7

Weight loss

• 1 kg
• 1.1 / -0.9

Alcohol intake

• 3.6 drinks/day
• 3.9 / -2.4

Aerobic exercise

120-150 min/week

• 4.9 / -3.7

Dietary patterns

DASH diet Hypertensive Normotensive

• 11.4 / -5.5
• 3.6 / -1.8

Applying the 2005 Canadian Hypertension Education Program recommendations: 3. Lifestyle modifications to prevent and treat hypertension Padwal R. et al. CMAJ ･ SEPT. 27, 2005; 173 (7) 749-751

* 2,300 mg sodium = 1 level teaspoon of table salt

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KIDNEY DISEASE MANAGEMENT: NON-SPECIFIC TREATMENTS

• BP control
• Target < 140/90 non-diabetic CKD, < 130/80 diabetic CKD
• ACE inhibitor &/or Angiotensin receptor blocker usual 1st line agent, especially if albuminuria

present

• Glycemic control if diabetic
• Dietary protein restriction
• Dietary sodium restriction
• General lifestyle: weight reduction, exercise, smoking cessation, vaccinations (influenza, pneumovax, +/-

Hepatitis B)

• Other:
• Acidosis correction (NaHCO3)
• ? Statin therapy
• ? Uric acid lowering therapy
• INFORM PATIENTS of their GFR & activate them with self-care (ie. BP monitoring, diet changes, tracking lab

data)