Chronic(Kidney(Disease( - IntermountainPhysician ·...
Transcript of Chronic(Kidney(Disease( - IntermountainPhysician ·...
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� Chronic Kidney Disease -‐ Arasu Gopinath, MD
October 31st 2014
Update in Medicine and Primary Care
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• Objec;ves
1. Why focus on CKD (2013 data) 2. Define CKD (KDIGO) 3. Staging/ Classifica;on CKD (KDIGO) 4. Iden;fy risks for developing CKD and for its
progression 5. Who to refer and when 6. When not to refer 7. Case scenarios
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• Effect of kidney func;on on homeosta;c processes
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• CKD is a worldwide public health problem
Global Kidney Disease series, The Lancet Vol 382 July 2013
Prevalence data by country
• WHY FOCUS ON CKD?
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• Many systemic diseases lead to CKD
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CKD reduces life expectancy
• WHY FOCUS ON CKD? CKD increases mortality
CKD increases morbidity CKD increases costs
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Case 1
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57 Yr old W male without PMH
• Presents with several weeks of feeling poorly but no other localizing symptoms
• No medica;ons • PMH-‐ nega;ve • Exam reveals HTN 165/90 but is otherwise non-‐focal
• Labs-‐ Creat 1.5 WBC 9K Hgb-‐11 eGFR-‐50 ml/min
• U/A 2+ blood and 2+ protein
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What would you do next?
A. Probable CKD. schedule FU in 3 month to repeat labs and confirm diagnosis
B. Probable CKD start lisinopril 20mg per day for HTN and proteinuria
C. Referral to Urology for evalua;on of hematuria D. Obtain old baseline labs and if not available
assume possible AKI given overall presenta;on E. Treat with ciprofloxacin for probable UTI
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What would you do next?
A. Probable CKD. schedule FU in 3 month to repeat labs and confirm diagnosis
B. Probable CKD start lisinopril 20mg per day for HTN and proteinuria
C. Referral to Urology for evalua;on of hematuria D. Obtain old baseline labs and if not available
assume possible AKI given overall presenta;on E. Treat with ciprofloxacin for probable UTI
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This is not CKD! • Baseline labs reveal Creat 0.9 in 2011 • Worrisome features include
– New onset HTN – Proteinuria – Hematuria (urine micro reveals RBC casts)
• Presenta;on most consistent with probable AKI and nephri;c syndrome
• Urgent referral to Nephrology is warranted • Renal Bx-‐ Pauci-‐immune GN • Treated appropriately baseline renal func;on now normal over 2 years out
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• DEFINITION OF CKD
KDIGO (2012) -‐ Kidney Disease Improving Global Outcomes
KDOQI (2002) - Kidney Disease Outcomes Quality Initiative
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• KDIGO 2012
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KDIGO 2012
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es;ma;ng GFR
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Es;ma;ng GFR
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Case 2
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75 YO W F with PMH significant for HTN
• Presents for annual follow-‐up; asymptoma;c • PMH-‐ HTN well controlled for 5 yrs; Hypothyroidism
• Medica;ons-‐ synthroid; amlodipine • Exam BP 138/90 normal exam, no edema • Labs-‐ K 5.0 Creat 1.1 eGFR-‐49mL/min • U/A-‐ normal; no proteinuria • Review baseline labs demonstrates Creat 1.1 2012 • Normal UA 2012
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1. What would you do next?
A. Diagnose CKD category G3a and obtain urinary albumin/creat to fully categorize
B. Obtain renal ultrasound to rule out obstruc;on
C. Obtain ANA, ANCA, C3/C4 and an; GBM ab D. Non-‐urgent referral to Nephrology E. All of the above
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1. What would you do next?
A. Diagnose CKD category G3a and obtain urinary albumin/creat to fully categorize
B. Obtain renal ultrasound to rule out obstruc;on
C. Obtain ANA, ANCA, C3/C4 and an; GBM ab D. Non-‐urgent referral to Nephrology E. All of the above
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• Why divide CKD into 3a and 3b
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Addi;onal Labs…
� UACR-‐ 70 mg/g � Calcium 8.5 � Phos-‐3.8 � Bicarb-‐24 � Albumin-‐ 4.0
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2. Would you improve her hypertension management? A. Add HCTZ 25mg daily to improve BP control
goal BP <130/80 B. Stop Amlodipine and start Losartan 50mg
daily to protect kidneys C. Stop Amlodipine and start Diovan/Tekturna D. Add Lisinopril 20 mg per day to current
regimen E. No change, con;nue Amlodipine, Goal BP
<150/90
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2. Would you improve her hypertension management? A. Add HCTZ 25mg daily to improve BP control
goal BP <130/80 B. Stop Amlodipine and start Losartan 50mg
daily to protect kidneys C. Stop Amlodipine and start Diovan/Tekturna D. Add Lisinopril 20 mg per day to current
regimen E. No change, con;nue Amlodipine, Goal BP
<150/90
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3. What diet should she be on?
A. Renal diet B. Low potassium diet C. Low phosphorus diet D. Low protein diet E. 2 gm sodium without other restric;ons
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3. What diet should she be on?
A. Renal diet B. Low potassium diet C. Low phosphorus diet D. Low protein diet E. 2 gm sodium without other restric;ons
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5. Will this pa;ent benefit from Nephrology referral? • No • reduc;on in eGFR is age and possibly hypertension related
• Mainstay of therapy is BP control (goal <150/90)
• Recommend a low salt diet • Annual FU with PCP most appropriate • Her risk for progressive kidney failure is extremely low ( < 1 % in 5 yr)
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WHEN TO REFER TO NEPHROLOGY
� eGFR < 30ml/min � albuminuria >300mg/g or proteinuria >500mg/24hrs
� progression of CKD
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WHEN ELSE TO REFER
• AKI or abrupt fall in GFR • Red cell casts • CKD and refractory hypertension • Persistent abnormali;es of Potassium • Recurrent or extensive nephrolithiasis • Hereditary kidney disease • Risk of CKD to ESRD is 10-‐20% in the next year
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4. What is her risk for progression to ESRD ?
A. 2 year-‐ 15%; 5 year-‐80% B. 2 year-‐ 10%; 5 year-‐60% C. 2 year-‐ 5%; 5 year-‐ 20% D. 2 year-‐ <1%; 5 year -‐ <1% E. Unknown risk
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4. What is her risk for progression to ESRD ?
A. 2 year-‐ 15%; 5 year-‐80% B. 2 year-‐ 10%; 5 year-‐60% C. 2 year-‐ 5%; 5 year-‐ 20% D. 2 year-‐ <1%; 5 year -‐ <1% E. Unknown risk
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• KIDNEY FAILURE RISK EQUATION
A Predictive Model for Progression of Chronic Kidney Disease to Kidney Failure - (Levey et al) JAMA. 2011;305(15):1553-1559.
2 & 5 yr risk calculation @ QxMD.com
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What is her risk for progression to ESRD ?
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Iden;fying risk for CKD progression
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Case 3
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52 Yr Hispanic female • PMH-‐ DM2 with re;nopathy; HTN; obesity • Family History – posi;ve for kidney failure requiring dialysis in mother and brother
• Medica;ons-‐ lisinopril 40 mg; merormin 1gm bid; ibuprofen for arthri;s; fenofibrate 145 mg
• Exam-‐ BP 168/90; BMI-‐38 • 2-‐3+ edema • Creat-‐1.4; eGFR-‐43ml/min; K-‐5.2; Bicarb 17 • U/A-‐ trace blood; 2+ protein • Creat 1.5 2013
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Next Steps?
A. Obtain addi;onal labs to fully categorize CKD and determine risk
B. Diagnose CKD presumed secondary to diabe;c nephropathy G3A3 and schedule FU in 1 year
C. Stop Merormin given reduced eGFR and add Actos
D. Stop Fenofibrate and NSAID, adjust BP meds and reevaluate in 3 months
E. Obtain renal ultrasound to rule out obstruc;on
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Next Steps?
A. Obtain addi;onal labs to fully categorize CKD and determine risk
B. Diagnose CKD presumed secondary to diabe;c nephropathy G3A3 and schedule FU in 1 year
C. Stop Merormin given reduced eGFR and add Actos
D. Stop Fenofibrate and NSAID, adjust BP meds and reevaluate in 3 months
E. Obtain renal ultrasound to rule out obstruc;on
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Addi;onal Labs…
• UACR-‐ 2800mg/gm • Calcium 8.2 • Phos-‐5.0 • Bicarb-‐17 • Albumin-‐ 3.2 • Hgb-‐ 9.8 • PTHi 248
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What is her risk for progressing to ESRD?
A. Cannot calculate has to be G4 or higher B. 2yr-‐5 %; 5 yr-‐ 20% C. 2yr-‐ 8%; 5yr-‐ 30% D. 2yr-‐ 15%; 5yr-‐ 40% E. 2yr-‐ 40%; 5 yr-‐ 90%
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What is her risk for progressing to ESRD?
A. Cannot calculate has to be G4 or higher B. 2yr-‐5 %; 5 yr-‐ 20% C. 2yr-‐ 8%; 5yr-‐ 30% D. 2yr-‐ 15%; 5yr-‐ 40% E. 2yr-‐ 40%; 5 yr-‐ 90%
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What is her risk of progressing to ESRD?
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RISK FACTORS FOR CKD
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Poten;al risk factors for developing CKD
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Family History of ESRD
• Diabe;c pa;ents with a posi;ve family history for Diabetes and ESRD
– Albuminuria was present in 46% – Only 1/3 had adequate BP control (<130/80) – Only 58% were receiving ACEI or ARB’s – Poor glycemic control and smoking were also common
• Especially true for Ethnic minori;es
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How would you manage her BP?
A. Stop Lisinopril given hyperkalemia (5.2) B. Add Chlorthalidone 25 mg per day Goal <
130/80 and see frequently un;l at goal C. Add Amlodipine 10 mg daily D. Add Losartan 100 mg daily (ONTARGET, ALTITUDE, VA
NEPHRON-‐D) E. Add Spirinolactone 25 mg daily
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How would you manage her BP?
A. Stop Lisinopril given hyperkalemia (5.2) B. Add Chlorthalidone 25 mg per day Goal <
130/80 and see frequently un;l at goal C. Add Amlodipine 10 mg daily D. Add Losartan 100 mg daily E. Add Spirinolactone 25 mg daily
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CKD complica;ons
• Hypertension • Anemia • Mineral Bone disorder • Acidosis • Hyperkalemia • Volume overload • Cardiovascular disease • Malnutri;on • Drug toxicity
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CKD complica;ons
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How would you treat her acidosis?
A. Add sodium bicarbonate 1300 mg bid for target bicarb 24
B. Low protein diet 0.8 gm/kg per day with mostly plant based proteins
C. Add fludrocor;sone 0.1 mg bid for RTA D. Add lasix 20 mg bid E. Both A&B
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How would you treat her acidosis?
A. Add sodium bicarbonate 1300 mg bid for target bicarb 24
B. Low protein diet 0.8 gm/kg per day with mostly plant based proteins
C. Add fludrocor;sone 0.1 mg bid for RTA D. Add lasix 20 mg bid E. Both A&B
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Acidosis
• Normal acid produc;on: 1 mEq/kg/day. • In CKD, kidneys are unable to excrete this amount due to :
– Reduced ammoniagenesis – Reduced filtra;on of ;tratable acids (sulfates, phosphates etc)
– Reduced proximal tubule bicarb reabsopr;on – Buffer therefore is oven phosphates and carbonates from the bone
– Chronic acidosis leads to bone demineraliza;on • Treat if serum bicarbonate < 22 mmol/ l • Oral bicarbonate supplements including Baking Soda (1 tsp =
60 mEq of bicarb)
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Copyright ©2009 American Society of Nephrology de Brito-Ashurst, I. et al. J Am Soc Nephrol 2009;20:2075-2084
Figure 3. Kaplan-Meier analysis to assess the probability of reaching ESRD for the two groups
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How do you manage her anemia?
A. Check iron stores and if sugges;ve of rela;ve iron deficiency-‐ add oral iron and follow
B. Transfuse 1 unit PRBC C. Start ESA and ;trate dose to target Hgb 13-‐14 D. Start ESA and ;trate dose to target Hgb 10-‐11 E. Recommend liver smothered in onions for
breakfast at least 3 ;mes per week
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How do you manage her anemia?
A. Check iron stores and if sugges;ve of rela;ve iron deficiency-‐ add oral iron and follow
B. Transfuse 1 unit PRBC C. Start ESA and ;trate dose to target Hgb 13-‐14 D. Start ESA and ;trate dose to target Hgb 10-‐11 E. Recommend liver smothered in onions for
breakfast at least 3 ;mes per week
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Anemia in CKD • Hgb < 13 g/dl in men, < 12 g/dl in women • Check annually if eGFR <30-‐59 ml/min/1.73 sq.m. • Check at least twice a year in eGFR < 30 ml/min/1.73 sq.m. • EPO level not necessary if CKD stage III or higher. • Rule out iron deficiency
– Ferri;n > 100 and/or Trans Sat > 20% – If either low give iron unless ferri;n >800. – Low threshold for IV iron – Oven anemia will correct with iron supplementa;on and will not require ESA.
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How to slow progression of kidney failure?
A. Correct metabolic acidosis B. More plant protein, less red meat C. Correct Anemia D. Diabetes control goal A1C <7.0% E. BP control goal <140/90 (?<130/80) F. A & B G. D & E H. All of the above. I. All of the above except C.
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How to slow progression of kidney failure?
A. Correct metabolic acidosis B. More plant protein, less red meat C. Correct Anemia D. Diabetes control goal A1C <7.0% E. BP control goal <140/90 (?<130/80) F. A & B G. D & E H. All of the above. I. All of the above except C.
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Delaying CKD progression • BP control and RAAS blockade • Limi;ng protein intake • Glycemic control • Avoiding AKI • Salt intake • Hyperuricemia (insufficient evidence) • Lifestyle changes
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Would she benefit from Nephrology referral ?
• Yes • She is high risk for progressive kidney failure • Her risk may be higher than calculated given her ethnicity and posi;ve family history
• she has mul;ple complica;ons of CKD
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What can Nephrology do for you/her?
• Co-‐manage HTN • Help manage CKD complica;ons • Educate, Educate, Educate about CKD and her risk for progressive kidney failure
• Planning for “right start dialysis” • More u;liza;on of Peritoneal Dialysis
– Less cost to the system – Probable bezer outcomes in the first 2 years
• Timely referral for transplant
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Planning for a Vascular Access • eGFR 30-‐59 ml/min (Cr ~ 1.5 -‐ 3 mg/dL)
– Preserve Access Sites ü Inform pa;ent not to allow venipuncture in non-‐dominant arm ü Avoid central lines ü No PICC lines
• Establish communica;on between nephrologist and PCP • Refer to surgeon for fistula when eGFR <25, or dialysis
an;cipated within 1 year • Fistula may take 3 to 4 months to mature • May not be needed for those who choose PD and are
transplant candidates
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Cardiovascular disease
� CKD pa;ents = highest CVD risk category
� CVD risk factors accelerate CKD
� CKD uniquely exacerbates CVD
� Most CKD pa;ents die of CVD before ESRD
� Majority of new ESRD pa;ents have CVD
� CKD pts need treatment for CVD risk reduc;on
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Probability of death aver AMI by CKD status
2010
Jan. 1 pt. prev. Medicare pts. age 66 & older; first CVD diag. in 2007–2008.
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Probability of death aver CVA/TIA
Jan. 1 pt. prev. Medicare pts. age 66 & older; first CVD diag. in 2007–2008.
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CKD-‐Mineral Bone Disorder
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CKD-‐Mineral Bone Disorder
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CKD-‐Mineral Bone Disorder
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Mineral Bone disorder
• Check serum Ca, Phos, PTHi and Alkaline Phosphatase at least once when eGFR < 45 ml/min/1.73 sq.m.
• Avoid rou;ne bone mineral density tes;ng in eGFR < 45 ml/min/1.73 sq.m.
• Avoid bisphosphonates in eGFR < 30 ml/min/1.73 sq.m. • When PTHi is high, screen for hyperphosphatemia,
hypocalcemia or Vitamin D deficiency.
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Timing of Dialysis
• Mostly symptom driven – Not simply based on eGFR
• Usual indica;ons such as hyperkalemia or fluid overload unresponsive to medical management
• No survival benefit to “early ini;a;on” • Increased risk for death if proper vascular access not in place
• Most pa;ents know when it is ;me based on symptoms – Flu that does not go away – ? Improved compliance
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Uremia
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83
0
3
6
9
12
15
18
-6 -5 -4 -3 -2 -1 1 2 3 4 5 6
Months pre- & post-initiation
PPPM
exp
endi
ture
s ($
, in
1,00
0s)
Medicare FFS
The Basis for the Integrated Care Strategy
Opportuni;es for Improving Outcomes and Cost
Slow CKD Progression
Prepare for Dialysis (50% crash into dialysis)
Smoother Transition into Dialysis (>30% mortality)
Manage Hospitalizations
(55% potentially avoidable)
Late Stage CKD Incident ESRD
Prevalent ESRD
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84
Clear Early Risk Prepara;on is Paramount
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Implementa;on of a CKD Checklist for Primary Care Providers
Clin J Am Soc Nephrol 9: 1526–1535, 2014 (Mendu et al)
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Implementa;on of a CKD Checklist for Primary Care Providers
Clin J Am Soc Nephrol 9: 1526–1535, 2014 (Mendu et al)
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Implementa;on of a CKD Checklist for Primary Care Providers
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Dos and don’ts in CKD • Use RAAS blockade when indicated • Preserve veins in non dominant arm • Avoid PICC and Mid lines where possible, esp in stages G4-‐5 • Avoid NSAIDs • Minimize contrast use and take appropriate precau;ons
when contrast is to be administered in stages G3-‐5 • Avoid Gadolinum for MRI in stage G4-‐5 • Minimize blood draws (coordinate with others where
possible) • Do not limit protein intake if malnourished
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Summary
-‐ Screen when risk factors are present -‐ Stage appropriately -‐ Resolve AKI and minimize risk for AKI -‐ Treat factors associated with progression -‐ Manage Cardiovascular risk -‐ Follow dos and don’ts -‐ Refer on ;me
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PCP – Nephrology partnership
• One quarter of pa;ents > age 60 have been iden;fied as having CKD G3 or worse – 8-‐9 million pa;ents – Not enough nephrologists to staff all pa;ents – Most will die before reaching ESRD – CKD G3b or worse will need management of comorbidi;es and their increased CKD induced CVD risk
– The PCP is essen;al in the care of CKD pa;ents