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ManagementofCKDandComplicationsinPrimaryCare

DeniseKLink,MPAS,PA-CTheUniversityofTexasSouthwesternMedicalCenter

AmericanAcademyofNephrologyPAsNationalKidneyFoundationCouncilofAdvanced

PractitionersAmericanAcademyPAliaisontoRenalPhysicians

AssociationDenise.Link@utsouthwestern.edu

NothingtoDisclose

Objectives• Recognizetreatmentgoalsforpreventingthe

progressionofCKDtowardESRDbyloweringbloodpressureandproteinuriatocurrentguidelinesthroughdietarychangesandinitiatingRAASblockademedication(s)

• InterpretthemostrecentguidelinesforbloodpressureofCKDpatients,goalsforDMwithCKD,treatmentsforCKDwithandwithoutproteinuria,ageofaCKDpatient,andco-morbiditiesofCKD

• DiscusshowtomanagethecomplicationsassociatedwiththetreatmentofCKD,includinghyperkalemia,fluidoverload,metabolicacidosisandproteinuria

ARS#1

WhichpatienthasaworseprognosisforCKDprogressiontoESRD?a) 75yoHTNeGFR 40ml/min,UACR150mg/gb) 22yoSLEeGFR 80ml/min,UACR3000mg/gc) 35yoADPKDeGFR 65ml/min,UACR100mg/gd) 55yoT2DMeGFR 50ml/min,UACR1500mg/

ARS#2

45yoobese,T2DM,DLD,CAD,HTN,hyperuricemia,CKDpresentswithworseningofrenalfunction.SCr increasedto2.0mg/dl.eGFRdecreasedfrom58to42ml/min. UACR2000mg/g.A1C8.5%.Youwould_____andrefertoendocrinology.a) Continuemetformin1000mgBIDb) Decreasemetformin500mgBIDc) Discontinuemetformin

ARS#3

65yomalewithT2DM,uncontrolledHTNandCKDpresentswithBP175/60,P80,BMI35.Scr 2.4mg/dl,eGFR 32ml/min,K4.8mEq/LA1c9.8%,UACR2,550mg/gMeds:MetoprololXL50mgdaily,HCTZ25mgdailyandinsulin• Whatbloodpressuremedicationchangeswouldyou

initiallymaketoachieveoptimalBPgoalto<130/80?a) DiscontinueHCTZandstartfurosemideb) IncreasemetoprololbasedonHRc) StartACEIorARBd) Alloftheabove.Isthisatrickquestion?

Numerous,sometimesconflictingCKDguidelinesà challengesprovidingappropriatecare

ManagingCKDinPrimaryCare

Making Sense of CKD

§ Designed to help PCPs manage adult CKD patients

§ Emphasizes key considerations for evaluating and managing CKD patients:

§ Identifying patients at highest risk for progression to kidney failure

§ Slowing progression among these high-risk patients

§ Highlights useful resources:

§ Patient education materials

§ Clinical tools

§ Professional reference materials

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RoleofPCPinCKDManagement

Nephrologyworkforce(n=7020)insufficientPCPscareformajorityofpatientswithCKDprovidingopportunitiesfor:• IdentificationofpatientsatriskforCKD• EarlyrecognitionofCKDanditsseverity• IdentificationandmanagementofCKDrisks• Engagementofpatientsinriskfactormodification• Timelyreferraltonephrologyandeffectivecare

coordination“Thebettertheprimarycare,thegreaterthecostsavings,thebetterthehealthoutcomes,andthegreaterthereductioninhealthand

healthcaredisparities”BarbaraStarfield,MD,MPH

PublicHealthBurdenofESRD

• Over600,000USadultshaveESRD

• Costoftreatment:- $75,000perperson/year

-ESRDcosttakesup6%ofMedicarebudgetdespitemakingup1%ofMedicarepopulation

• Associatedwithpoorsurvivalandqualityoflife

USRDS2013/14AnnualDataReport

PublicHealthBurdenofCKD• Averageestimatedall-causecostperpatentin2016:ComparingstandardofcarewithRAASinthosewithoutCKDtothosewithCKD.93,912<65yoand81,829>65yo

• Newresearchshowsthattheall-causecoststoMedicareandprivateinsurersfortreatingCKDpatientsrapidlyincreaseasthediseaseprogresses.

CommercialInsurance Medicare

NoCKD $7500 $8100

Stage3a CKD(GFR45-59ml/min)

$27,200 $20,500

Stage4-5 CKDGFR(0-29ml/min)

$77,000 $46,100

Golestaneh,etal.“HealthcareCostRisesExponentiallybyStageofChronicKidneyDisease”(KidneyWeek2016,Abstract2289)

1,120,295AmbulatoryAdults

Goetal.N.Engl.J.Med351:1296,2004

36.60

21.80

11.29

3.652.11Ra

teofC

ardiov

ascular

Even

ts(p

er100

person-yr)

EstimatedGFR(ml/min/1.73m2)

No.ofEvents 73,108 34,690 18,580 8809 3824

≥60 45-59 30-44 15-29 <15

10

40

15

30

35

20

25

0

5

RateofD

eathfrom

Any

Cau

se

(per100

person-yr)

≥60 45-59 30-44 15-29 <15

EstimatedGFR(ml/min/1.73m2)

No.ofEvents25,803 11,569 7802 4408 1842

14.14

11.36

4.76

1.080.76

1514131211109876543210

1501401301201101009080706050403020100

144.61

86.75

45.26

17.2213.54RateofH

ospitalization

(per100

person-yr)

EstimatedGFR(ml/min/1.73m2)

No.ofEvents366,757 106,543 49,177 20,58111,593

≥60 45-59 30-44 15-29 <15

Death CVEvents Hospitalization

PublicHealthBurdenofCKDAssociatedwithPoorClinicalOutcomes

PatientAwarenessofCKDislow

USRDS2014AnnualDataReport

LifetimeIncidenceofCKDStages3-5intheUSis59%*

A60%chanceofhaveCKDisequivalenttosayingthat80%ofAmericanswilldevelopoldage.Toughbuttrue.

PaulW.Eggers,PhDProgramDirectorforKidneyandUrologyEpidemiologyNationalInstituteofDiabetesandDigestiveandKidneyDiseases

*GramsME,ChowEKH,Segev DL.LifetimeincidenceofCKDStages3-5intheUnitedStates.AmJKidneyDisease,2013

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ESRD=KidneyFailure

100

80

60

40

20

ProgressiveKidneyDisease

Time(yrs)2 4 6 810

Normal(0.8ml/min/yr)

30yearold

Requires Repeated Measures of GFR Over Time

DiseaseProgressionofCKD SadieCKDorAGING?

85y/oNIDDM

eGFR 45ml/min

Ifyoulose1%/yr abovetheageof30,

85y/o=55yearsofGFRlossOr

100-55or45ml/min

ESRDTreatmentsDialysisandTransplantation

Peritoneal Dialysis(PD)usestheperitonealliningtofiltertheblood

Hemodialysis(HD)usesamachineandfiltersthebloodoutsidethebody

“PatientswithCKD,particularlythosewithESRDareamongthemostsymptomaticofanychronicdiseasegroup.”

Murtagh F,Weisbord S.Symptomsinrenaldisease.InChambersEJetal(eds)SupportiveCarefortheRenalPatient 2010,2nd ed,OUP.

TheESRDPatient

• Substantial impaired health-relatedqualityoflife• Tremendoussymptomburden• Thenumberandseverityofphysicalandmentalsymptomsaresimilartothoseofmanycancerpatientshospitalizedinpalliativecaresettings

• Symptomsincludepain,insomnia,nausea,anorexia,pruritus,severefatigueandSOB

• Unlike manycancer patients,thesesymptomsareoftenpresentforseveralYEARS

PredictorsofAdverseRenalandCardiovascularOutcomes

• Age

• Hyperglycemia

• Hypertension

• Albuminuria

• ActivationofRAAS

• FamilyHistory(renal)

• Ethnicity

• Race

• Hypoalbuminemia

• NT-proBNP/TroponinT

• C-reactiveprotein

• Smoking1.Keaneetal.Kid.Int.2003,63:1499-15072.Parving etal.KidInt69:2057–2063,20063.McMurrayetal.AmHeartJ.2011Oct;162(4):748-7554.Desaietal.AmJKidneyDis.2011Nov;58(5):717-28.

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CriteriaforCKDWhereistheSCr?

1. DecreasedGFR≤60ml/minfor>3months

2.MarkersofKidneyDamagefor>3months• Albuminuria≥30mg/g(UACR)• Urinarysedimentabnormalities

Ex:microhematuria• Electrolyteandotherabnormalitiesduetotubular

disorders• Structuralabnormalitiesdetectedbyimaging

Ex:ADPKD(polycystickidneydisease)• Historyofkidneytransplantation

or

WhichGFR?• Glofil=true/accurateGFR• eCrCl usingCockcroft-Gaultformula• eGFR usingModificationofDietin

RenalDisease(MDRD)formula• eGFR usingtheCKD-EPIformula• eGFR usingtheMayoQuadraticformula• eGFR forchildrenusingSchwartzformula• CystatinC• CreatinineClearance(CrCl)

NotenoughvariabilitytochangeStageofKidneyDisease

CKDStageswithPrognosis

KDIGO2012ClinicalPracticeGuidelinefortheEvaluationandManagementofCKD,KidneyInternational,Jan2013,Vol 3,Issue1

Primaryfocalandsegmentalglomeruloscleorosis(nephroticproteinuria)

Type2diabetes(20-40%)

Remuzzi,G.etal.J.Clin.Invest.116:288-296,2006

GFR(m

l/min)

0

20

40

120

60

80

100

400 302010Timeafterdiagnosis(yr)

ADPKD(PKD1 mutation)

DeclineinGFRvariesbyDiseaseState,FromPatienttoPatientandisAccelerated

inthosewithAlbuminuria

AlbuminuriaIsaPrognosticIndicator

ProteinuriaandRateofChangeinKidneyFunctioninaCommunityBasedPopulation,JASM2013

TheProgressionofCKD:A10-yearpopulation-basedstudyoftheeffectsofgenderandage.KI2006

TherelationshipbetweenmagnitudeofproteinuriareductionandtheriskofESRD:ResultsoftheAASKstudyofkidneydiseaseandhypertensionAchInternMed2001

CombiningGFRandalbuminuriatoclassifyCKDimprovespredictionofESRD,JASN2009

AlbertaKidneyDiseaseNetwork:Relationbetweenkidneyfunction,proteinuria,andadverseoutcomes,JAMA2010

PrevalenceofCKDComplications

Moranne O.etal.JAmSoc Nephrol 20:164-171,2009.

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SignsandSymptoms

• DecreasingGFR• Increasingalbuminuria• UncontrolledHTN• ImprovedDMmanagement(Why?)

• Hyperkalemia• Metabolicacidosis• Anemia• Hyperphosphatemia• Hyperparathyroid• Hypovitaminosis D

• Nausea,vomiting,poorappetite,weightloss

• Troublesleeping• Fatigue• Nocturia• Dry,itchyskin• Legcramping(night?)• Skincolorchanges• SOB• Edema• Confusion

ManagementofCKD

1. Screenatriskpatients2. DeterminelevelofrenalfunctionwitheGFR3. Determineprognosiswithalbuminuria4. AddRAASblockadeifalbuminuriaispresent5. Bloodpressuretogoal?6. DiabetesA1C?7. Smokingcessation8. Weightloss9. LimitingfutureAKI

CKDRiskFactors

• Diabetic• Hypertensive• Olderage(>60y/o)• RecurrentUTI• Kidneystones• HistoryofAKI• Autoimmunedisease:Lupus,Sjogrens,RA,MCTD…

• FamilyhistoryofCKD• CVD• Neoplasm:multiplemyeloma,Wilms,kidneycancer

• Previoustransplant• Previouskidneydonor

1.KDOQIguidelines20022.http://www.uspreventiveservicestaskforce.org/uspstf/uspsckd.htm

ManagementofCKD

1. Screenatriskpatients2. DetermineandtrendrenalfunctionwitheGFR3. Determineprognosiswithalbuminuria4. AddRAASblockadeifalbuminuriaispresent5. Bloodpressuretogoal?6. DiabetesA1C?7. Smokingcessation8. Weightloss9. LimitingfutureAKI

45y/owhiteFemaleeGFR39Stage3b

17y/onon-whiteMaleeGFR80Stage1

70y/owhiteFemaleeGFR 30

Stage3b/borderline4

70y/onon-whiteMaleeGFR60Stage2

HoldSCrstableat1.5

WhatistheGFR?

R.K.isa53yomalewhohasadvancedliverdiseaseandnephroticproteinuria

Scr0.55mg/dl eGFR 177ml/min 20030.63mg/dl 20040.77mg/dl 20050.86mg/dl 20061.2mg/dl eGFR63ml/min 2008

TrendingRenalFunction:eGFR/Scr

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ManagementofCKD

1. Screenatriskpatients2. DetermineandtrendrenalfunctionwitheGFR3. Determineprognosiswithalbuminuria4. AddRAASblockadeifalbuminuriaispresent5. Bloodpressuretogoal?6. DiabetesA1C?7. Smokingcessation8. Weightloss9. LimitingfutureAKI

ProteinuriavsAlbuminuria

MorningUACR

UACR>30and<300mg/gModeratealbuminuria

UACR300mg/gSeverealbuminuria

Confirmedwithin3months

InterventionàTx:1.AddACEi ORARB2.LowerBP<130/803.BeginlowSodiumdiet

Monitorq3-6months

Unconfirmed

Monitorannually

EvaluationofAlbuminuria

SpecialThankstoScottandWhiteofTempleTXforuseoftheirkidneycomic

Urineproteintocreatinineratio(UPCR)

24hoururinefortotalprotein

Urinealbumintocreatinineratio(UACR)

UrinaryproteinOralbumin

QuantifyingALBUMINURIA:WhereistheUAdipstick?

ManagementofCKD

1. Screenatriskpatients2. DetermineandtrendrenalfunctionwitheGFR3. Determineprognosiswithalbuminuria4. AddRAASblockadeifalbuminuriaispresent5. Bloodpressuretogoal?6. DiabetesA1C?7. Smokingcessation8. Weightloss9. LimitingfutureAKI

ASSKStudy

AlbuminuriamoredetrimentaltohypertensiveblackpatientsLongactingARBmoreeffectivethanshort.Costvssideeffects

Takingthemedicationworksbetterthannot,NOmatterwhichdrug!

RAASBlockade

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Aldosterone

+

Inhibition ofRAAS:leadstolessproteinuria1.ACEIs• Blockconversionofangiotensin I

toangiotensin II• Increaseavailabilityofbradykinin

2.ARBs• Selectivelyantagonizeangiotensin II• Mayalsomodulatetheeffectsof

angiotensin IIbreakdownproducts

WeirMR.Clin Ther.2007;29(9):1803-1824.

Renin

Angiotensinogen Angiotensin IACE

Angiotensin II

Renin-Angiotensin-AldosteroneSystem(RAAS)

RAAS inhibition provides nephroprotectionindependent of blood pressure lowering

2000

20

2

200

Albu

minuria(µ

g/min)

40%

60%Normoalbuminuria

Overtnephropathy

Microalbuminuria

Time(Years)

IDNT

RENAAL

IRMA2

ΔGFR2-20:10

ΔGFR1-3

ΔGFR1

BENEDICT

ROADMAP

Parving etalNewEngl.J.Med 2001,LewisetalNewEngl.J.Med 2001,BrenneretalNewEngl.J.Med 2001,Ruggenenti etalNewEngl.J.Med 2004

BlockadeoftheRAASSlowsorPreventsOnsetandProgressionofDiabeticKidneyDiseaseinHypertensiveType2Diabetics

ACEi orARBsevenwithAdvancedCKD

20-30%bumpinSCrisnormal.Thisshouldbeexpected.Repeatlabsin2weeks

ACEi + ARB=DualBlockadeEfficacyandsafetyofdualblockadeoftherenin-angiotensin

system:meta-analysisofrandomizedtrials Jan2013

DualBlockademeans- IncreasedriskofComplicationsAnd

Nodecreaseinmortality

Complicationsinclude:Hyperkalemia,hypotension,andkidneyfailure

ACEInhibitorandAngiotensinReceptor-IIAntagonistPrescribingandHospitalAdmissionswithAcuteKidneyInjury:ALongitudinalEcologicalStudy

IncreasedriskofAKIwithACEi/ARB

StrategiestoLowerAlbuminuriaMulti-RiskFactorInterventions

1. ControlBPtogoalof<130/80.(MDRD,ABCDAASK)LoweringBPbyitselfwillreducealbuminuriaby~50%orpreventsthe2-3x↑inalbuminuriaobservedinpatientwithusualBPgoal

2. BlockageofRAAS3. RestrictNaCl intake.Highsodiumintakewill

overrideanti-albuminuric effectsofACEi/ARBs4. AldosteroneantagonisticTx:spironolactone5. Smokingcessation6. Reduceobesity

ManagementofCKD

1. Screenatriskpatients2. DetermineandtrendrenalfunctionwitheGFR3. Determineprognosiswithalbuminuria4. AddRAASblockadeifalbuminuriaispresent5. Bloodpressuretogoal?6. DiabetesA1C?7. Smokingcessation8. Weightloss9. LimitingfutureAKI

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130 134 138 142 146 150 154 170 180

r=0.52;P <0.01

SystolicBloodPressure(mmHg)

DeclineinGFR

from

Baseline

(ml/min/year) Untreated

HTN

0

-2

-4

-6

-8

-10

-12

-14

ModifiedfromBakrisGLet.al.AmJKidneyDis,Sept.2000

Trialsincluded:MDRD,RENAAL,IDNT,AIPRI,CaptoprilTrail,REIN,AASK

LoweringBloodPressureSlowsProgressionofChronicKidneyDisease

IncidenceofallRenalEventsaccordingtoachievedBPlevels:ADVANCETRIAL

deGalanetal.JAmSocNephrol20:883–892,2009

RenalEvent=Newonsetorworseningalbuminuria,DoublingserumcreatinineandESRD

WhatBPTargetsshouldweStrivetoAchieve?

ComparisonofBPGuidelinesGuideline Population GoalBP

mmHgInitialdrugtreatmentoption

JNC8 General>60 yoGeneral<60yoDMCKD

<150/90<140/90<140/90<140/90

NB:thiazide,ACEi, ARBorCCBBL:thiazideorCCBDM:thiazide,ACEi,ARBorCCBCKD:ACEi orARB

KDIGO2012

CKDnoproteinuriaCKD+proteinuriaDM &CKDnoproteinuriaDM &CKD+proteinuria

<140/90<130/80<140/90<130/80

ACEi orARB

ACEi orARB

KDOQI2004

DM+CKDCKDwithproteinuriaCKDwithoutproteinuria

<130/80<130/80<130/80

ACEi/ARBACEiNopreference

NB-nonblack,BL-black,ACEi-angiotensinconvertingenzymeinhibitors,ARB-angiotensinreceptorblocker,CCB-calciumchannelblocker

LifestyleModification

Modification ApproximateSBPreduction

Weightreduction 5–20 mmHg/10kgwt loss

AdoptDASHdiet 8–14mmHg

Dietarysodium 2–8mmHg

Physicalactivity 4–9mmHg

Moderationofalcoholconsumption

2–4mmHg

Total=↓21mmHg

ManagementofCKD

1. Screenatriskpatients2. DetermineandtrendrenalfunctionwitheGFR3. Determineprognosiswithalbuminuria4. AddRAASblockadeifalbuminuriaispresent5. Bloodpressuretogoal?6. DiabetesA1C?7. Smokingcessation8. Weightloss9. LimitingfutureAKI

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A1CGoal7%

CKD4,5,5D=7.5%

MetforminDosing

USFoodandDrugAdministrationPrescribingGuidelinesforMetforminasRelatedtoKidneyFunctionMetforminiscontraindicatedin“renaldiseaseorrenaldysfunction(eg,assuggestedbyserumcreatininelevels≥1.5mg/dL [males],≥1.4mg/dL [females])orabnormalcreatinineclearance(CrCl).”Metformin“shouldnotbeinitiatedinpatients≥80yearsofageunlessmeasurementofcreatinineclearancedemonstratesthatrenalfunctionisnotreduced.”

TheNewFDAMetforminDosing

• PIstatesmetformincanbeuseduntilGFRof30ml/min(4/11/16)

• Basedonstudiesshowinglittlechanceoflacticacidosis

• Veryfewreportsoflacticacidosisin‘realpractice’– CollectedviaMedWatch (FDASafetyInformationandAdverseEventReportingProgram)

– Doyoureportknownsideeffectsofmedications?

StrategyMetforminRxinCKD

JAMA.MetformininPatientsWithType2Diabetes&KidneyDis:SystematicReview2014;312(24):2668-2675

ManagementofCKD

1. Screenatriskpatients2. DetermineandtrendrenalfunctionwitheGFR3. Determineprognosiswithalbuminuria4. AddRAASblockadeifalbuminuriaispresent5. Bloodpressuretogoal?6. DiabetesA1C?7. Smokingcessation8. Weightloss9. LimitingfutureAKI

ManagementofCKD

1. Screenatriskpatients2. DeterminelevelofrenalfunctionwitheGFR3. Determineprognosiswithalbuminuria4. AddRAASblockadeifalbuminuriaispresent5. Bloodpressuretogoal?6. DiabetesA1C?7. Smokingcessation8. Weightloss9. LimitingfutureAKI

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IatrogenicAKI Preventableevents→AKI→CKDprogression→ESRD

ComplicationsofCKD

1. Hyperkalemia2. Fluidoverload3. Metabolicacidosis4. Anemia5. Hyperparathyroid/hyperphosphatemia6. Depression7. Malnutrition

ComplicationsofCKD

1. Hyperkalemia2. Fluidoverload3. Metabolicacidosis4. Anemia5. Hyperparathyroid/hyperphosphatemia6. Depression7. Malnutrition

CasePresentation65yofemalewithCKDstage4,CAD,DMwithretinopathy,HTN,CHFandobesitywhopresentsfor3monthfollowupondiabetesmanagement.

• BP160/85,P60,weight250lbs• PErevealsS4and+1edema• LabsrevealedstableSCr 2.5mg/dl,BUN20,eGFR 20ml/min,Na+

140,K+6.5,CO220,spoturinealb/cr 2500mg/g.• Currentmeds:HCTZ25mgdaily,potassiumchloride20mEqBID,

lisinopril 40mgBID,labetalol300mgTID,ibuprofen400mgBID,spironolactone12.5mgBID

1. Whatarethepossiblecausesofhyperkalemia?2. Whatchangesshouldbemade

toachieveoptimalBP?

Question1

Whatarethepossiblecausesofhyperkalemia?a) Medsb) CKDc) Dietd) K+supplementse) Metabolicacidosisf) Alloftheabove

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Question1b

Whichofhermedicationscouldhaveledtohyperkalemia?a) Lisinoprilb) Labetalolc) Ibuprofend) Spironolactonee) Potassiumchloridef) a,d,andeg) Alloftheabove

Question2

WhatchangesshouldbemadetoachieveoptimalBP?a) Followinglowsodiumdietb) Medicationcompliancec) OTCmeds?d) DiscontinueHCTZ.e) Starttorsemidef) Startfurosemideg) Alloftheabove

Diuretics:Keytosuccess• LoopdiureticswheneGFR <30-50ml/min• DonotusethiazidediureticswheneGFR <30-50ml/min.Theydonotwork

with↓kidneyfunction• PlacebopillwithhighNaCl intake• Ifpatientsrequirepotassiumsupplementation=NOTcompliantwithlow

NaCl intake• Oncedailyloop• Torsemide morebioavailablethanfurosemide

Use50%doseoffurosemide.ParticularlywithmorealbuminuriaEx:Furosemide40mgBID =Torsemide 40mgdaily

• TreatsMANYcomplicationsofCKD1. Hyperkalemia2. Fluidoverload3. ElevatedBPs4. Metabolicacidosis5. UsageofACEi/ARBto↓albuminuria

Question3AfterdiscontinuingHCTZ,ibuprofenandpotassiumchlorideandinitiationoftorsemide 20mgQAM,repeatlabsreveal:• ↑inSCr 2.5to2.9mg/dl,BUN24,↓ineGFR from20to18ml/min,↓SK+5.5,↑CO222,↓UACR1500mg/g.

• BP145/80,P60,weight250lbs• Traceto+1LEedemaMeds:lisinopril 40mgBID,labetalol300mgTID,spironolactone12.5mgBIDandtorsemide 20mgQAM

Whatisyournextstep?

Question31. Decreaselisinopril to40mgdailydueto↑inSCr

and↓eGFR2. Decreasetorsemide to10mgdueto↑inSCr and

↓eGFR3. Increasetorsemide to30mgdailyto↓SK+,↑CO2,

↓LEedema,↓BPtogoalof<130/804. Discontinuespironolactoneandstartcalcium

channelblocker5. ReassessNaCl with24hrurinesodiumtoensure

<200mmol/24hrindicatinglowNaCl intake*RememberhighNaCl rendersRAASblockadeanddiureticslessefficacious=PLACEBOPILLS

ARS#1

WhichpatienthasaworseprognosisforCKDprogressiontoESRD?a) 75yoHTNeGFR 40ml/min,UACR150mg/gb) 22yoSLEeGFR 80ml/min,UACR3000mg/gc) 35yoADPKDeGFR 65ml/min,UACR100mg/gd) 55yoT2DMeGFR 50ml/min,UACR1500mg/

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ARS#2

45yoobese,T2DM,DLD,CAD,HTN,hyperuricemia,CKDpresentswithworseningofrenalfunction.SCr increasedto2.0mg/dl.eGFRdecreasedfrom58to42ml/min. UACR2000mg/g.A1C8.5%.Youwould_____andrefertoendocrinology.a) Continuemetformin1000mgBIDb) Decreasemetformin500mgBIDc) Discontinuemetformin

ARS#3

65yomalewithT2DM,uncontrolledHTNandCKDpresentswithBP175/60,P80,BMI35.Scr 2.4mg/dl,eGFR 32ml/min,K4.8mEq/LA1c9.8%,UACR2,550mg/gMeds:MetoprololXL50mgdaily,HCTZ25mgdailyandinsulin• Whatbloodpressuremedicationchangeswouldyou

initiallymaketoachieveoptimalBPgoalto<130/80?a) DiscontinueHCTZandstartfurosemideb) IncreasemetoprololbasedonHRc) StartACEIorARBd) Alloftheabove.Isthisatrickquestion?

Questions?

Denise.Link@utsouthwestern.edu.

Thankyouforyourtime