Pearl #1: A “normal” serum creatinine may not be normal

Chronic Kidney Disease

For the Primary Care Physician

Monita Poudyal, M.D.

February 6-8, 2020
Pearl #1: A “normal” serum creatinine may not be normal

DISCLOSURES
None

Monita Poudyal, M.D.

February 6-8, 2020
 Objectives

1. Understand the definition of CKD and how to screen for it

2. Implement strategies to decrease the progression of CKD
3. Understand how new diabetes drugs impact CKD care
4. Understand how to manage anemia associated with CKD
5. Know when to refer patients to Nephrology
6. Understand that advanced CKD profoundly affects QOL
7. Understand the effect of dialysis on the elderly and the importance of
defining goals of care in this population
 What is Chronic Kidney Disease?

Case Study: Mrs. A is a 62 yo Caucasion woman with DM, HTN, gout and
osteoarthritis. She takes Celebrex, metformin and hydrochlorothiazide
and has a stable serum creatinine of 0.9 mg/dl, eGFR 67ml/min/1.72m2
over the past 6 months.

Does she have chronic kidney disease?

A. Maybe, we need more information
B. No, her creatinine is normal
C. No, her eGFR is normal for her age
D. Both B and C
 #1: A “normal” serum
Definition creatinineKidney
of Chronic may not beDisease
normal

Kidney damage or GFR <60 mL/min / 1.73 m2 for >3 mo

Kidney damage can be either functional or structural
➢ Functional abnormalities
-- Proteinuria, albuminuria
-- Electrolyte abnormalities due to tubular disorder
-- Abnormalities of urinary sediment (dysmorphic red cells,
cell casts)
➢ Structural abnormalities
-- On radiological evaluation
-- Polycystic kidney disease, reflux nephropathy, etc
-- On biopsy
-- Transplanted kidney
A Levey, et al. Kidney International (2011) 80, 17–28
 Classifying Chronic Kidney Disease
CKD classification according to GFR

Ccc

Chart adapted from UpToDate.com

 Classifying Chronic Kidney Disease
CKD classification according to Albuminuria

Ccc

Chart adapted from UpToDate.com

 Classification
#1: A “normal”Corresponds
serum creatinineto Severity
may and Prognosis
not be normal

Risk of ESRD, AKI, CV, or Death

Low

Moderate

High

Very high

Stage 1 55 %
Stage 2
33%
Stage 3a

Stage 3b
12%
Stage 4
Kidney Disease: Improving Global Outcomes (KDIGO)
CKD Work Group. Kidney Int Suppls. 2013;3:1-150.
Stage 5
 Classifying Chronic Kidney Disease
Back to Mrs. A
62 yo Caucasion woman
with DM , HTN, OA, gout
SCr 0.9, eGFR 67
UACR 550mg/g
UA 2+ prot, no
cells, +gluc

Diagnosis: Diabetic
Kidney Disease
 Screen those at greatest risk
Genetic Factors Sociodemographic Factors
➢ Diabetes mellitus ➢ Older age
➢ Hypertension ➢ Black race

➢ Cardiovascular disease ➢ Smoking

➢ Heavy alcohol use
➢ Urological disorders, esp
obstructive uropathies ➢ Obesity
➢ FMHx of polycystic kidney dz ➢ NSAIDs

➢ Autoimmune diseases
 Screening tools for CKD

Screening: estimate GFR and test for

kidney damage markers
❑Serum creatinine and estimated GFR
❑Urinalysis for leukocytes and
dysmorphic red blood cells and casts
❑ Urine albumin-to-creatinine ratio
❑ Renal ultrasound
 Slowing progression of CKD
Case Study: Mrs. A is a 62yo Caucasion woman with DM , HTN, OA, gout.
EGFR 67 ml/min/1.73m2, UACR 550mg/g. She is confirmed to have CKD
stage G2A3.
For Mrs. A, there is data that prevention of CKD
progression might include all of the following
EXCEPT:

A. Treating hypertension
B. Using ACEi or ARB
C. Improving diabetic control
D. Correcting metabolic acidosis
E. Treating hyperuricemia
 Slowing progression of CKD: Hypertension

Hypertension is a significant
risk factor for development
of end-stage renal disease1
Incidence of ESRD

Years since screening 1. Hypertension. 2003;41:1341–1345

 Slowing progression of CKD: Hypertension
Aggressive BP control is more effective in delaying progression in proteinuric CKD

Jafar et al. Annals of Internal Medicine 2003;

139: 244-252.
 Slowing progression of CKD: Hypertension

KDIGO Guidelines for Blood pressure

control1
➢ ACR <30 mg/g: ≤140/90 mm Hg
➢ ACR 30-300 mg/g: ≤130/80 mm Hg (or
<140/90)*
➢ ACR >300 mg/g: ≤130/80 mm Hg
➢ Individualize BP targets and meds according
to age, coexistent CVD, and other
comorbidities
*Reasonable to select a goal of 140/90 mm Hg, especially for moderate albuminuria
(ACR 30-300 mg/g.)2
1) Kidney Disease: Improving Global Outcomes (KDIGO) Blood Pressure Work Group.
Kidney Int Suppl. (2012);2:341-342.
2) KDOQI Commentary on KDIGO Blood Pressure Guidelines. Am J Kidney Dis.
2013;62:201-213.
 Slowing progression of CKD: ACEi/ARBs
ACEi decreases risk of ESRD/doubling creatinine, but only for
proteinuria >500mg/day
Relative Risk

1 2 3 4 5 6 7 8 9 10
Proteinuria g/d Jafar et al. Ann Int Med. 2001:135:72-87
N Engl J Med 369: 1892–1903, 2013

Slowing progression of CKD: ACEi/ARBs

KDIGO Guidelines: Use ACEi or

ARBs1
➢ Diabetics with ACR 30-300 mg/g
➢ Diabetics and nondiabetics with ACR
>300 mg/g
➢ Combination of ACEi and ARB is not
recommended (high risk of impaired
kidney function and hyperkalemia) 2
1. Kidney Disease: Improving Global Outcomes (KDIGO) Blood
Pressure Work Group. Kidney Int Suppl. (2012);2:341-342
2. Fried, et al. N Engl. J Med 369:1892-1903, 2013
 Additional thoughts on Hypertension

Additional thoughts on HTN management:

➢ Low salt diet (2gm/day) and diuretics can augment ACEi/ARBs
effectiveness in controlling BP and proteinuria
➢ Diuretics are typically necessary for BP and volume in CKD
-- Thiazides are effective in CKD G1-3
-- Loop diuretics may be needed in CKD G4 or greater
➢ Nondihydropyridine calcium channel blockers(diltiazem,
verapamil) can help in proteinuria reduction
➢ For the elderly:
-- If ambulatory and healthy, same general BP targets
-- If fragile, tailor medications and BP targets to the individual
 Practical issues with ACEi/ARBs
Case Study: Mrs. A with CKD has 550mg albuminuria. She takes
metformin, HCTZ and Celebrex. You add Lisinopril and maintain
BP<130/80. One month later, her creatinine in 1.2 (baseline 0.9).
What would be the LEAST appropriate next step?
A. As long as K+ is ok, continue Lisinopril
B. Stop Celebrex and recheck creatinine in 1 month
C. Stop HCTZ and recheck creatinine in 1 month
D. Stop Lisinopril and check for renal artery stenosis

Do not ignore a rise in creatinine >25% after initiation of ACEi/ARB

 ACEi/ARBs in advanced CKD
Case Study: Mr. B is a 72 yo AA man with stage G5 (eGFR 17) CKD and is
being prepared for dialysis. He has ischemic cardiomyopathy and diabetes.
Meds: Lisinopril, Metoprolol, Insulin, Torsemide, Rosuvastatin, and ASA.

What is the data on stopping RAAS inhibitors in advanced CKD?

A. RAAS inhibitors have significant cardiovascular protective
benefits in advanced CKD, so discontinuation is not advised
B. Discontinuation of RAAS inhibitors may allow for improved GFR and
postponement of dialysis
C. Discontinuation of RAAS inhibitors might accelerate kidney damage,
so should be avoided
 ACEi/ARBs in advanced CKD
ACEi discontinuation improves eGFR in advanced CKD:
a small observational study

N= 52
Avg eGFR 16 ml/min

Ahmed et al. Nephrol Dial Transpl (2010) 25: 3977-3982

 ACEi/ARBs in advanced CKD
The decision to continue or discontinue ACE inhibitor/ARB use
at CKD stage 4 or 5 is controversial
Providing
cardiovascular
Delaying dialysis protection

No ACEi ACEi
?
 Slowing progression of CKD: Acidosis
CKD causes acidosis which in turn perpetuates renal injury. Mechanisms:

Am J Kidney Dis. 2016 Feb;67(2):307-17

 Slowing progression of CKD: Acidosis
Retrospective Cohort Study: Bicarbonate level < 22 mmol/L associated
with progression of kidney disease, independent of baseline eGFR

N= 5422

Shah et al. Am J Kidney Dis. 2009 Aug;54(2):270-7

 Slowing progression of CKD: Acidosis
Key Points on Metabolic acidosis:
➢ Seldom significant until GFR <30 mL/min
➢ Contributes to CKD progression, insulin resistance,
decreased cardiorespiratory fitness, altered bone
metabolism
➢ Meta-analysis of small RCTs: Bicarbonate
supplementation in CKD improves kidney functiona
➢ Use alkali therapy with serum bicarbonate <22 mmol/L
to maintain serum bicarbonate levels >22b and within
normal rangec
➢ Typical prescription: 650mg sodium bicarbonate bid,
up to 1300mg bid (watch for volume overload!)

a. Susantitaphong et al. Am Journal of Nephr. 2012;35(6):540-7

b. Vassalotti, et al. American Journal of Medicine (2016) 129, 153-162
c. Kidney Disease: Improving Global Outcomes (KDIGO) CKD Work Group. Kidney Int Suppls. 2013;3:1-150.
 Slowing progression of CKD: Diabetes Mellitus

➢Good glycemic control reduces:

➢Progression of CKD
➢Incidence proteinuria
➢KDIGO CKD guidelines recommend a goal A1c level ~7% 1
➢ADA recommends goal A1c level <8% for patients at risk
for hypoglycemia (advanced age, vascular disease, CKD,
multiple comorbidities) 2

1. Kidney Disease: Improving Global Outcomes

(KDIGO) CKD Work Group. Kidney Int Suppls.
2013;3:1-150.
2. Diabetes Care 2018;42(Suppl. 1):S1–S194.
 The Kidneys and Glucose Homeostasis
Kidney’s Role in Glucose Homeostasis1:
1. Gluconeogenesis
2. Glucose resorption from filtrate

As GFR declines, you get:

1. capacity for renal gluconeogenesis
2. elimination of glucose lowering drugs.
3. peripheral degradation of insulin
4. Uremia, anorexia, low glycogen stores

Hypoglycemia is a real threat in CKD,

with or without diabetes2
1. J Am Soc Nephrol 28: 2263–2274, 2017
2. Moen, et al. CJASN June 2009, 4 (6) 1121-1127
 Slowing progression of CKD: Summary

Decrease CKD progression by:

➢ Treating hypertension
Goal BP<140/90 if no albuminuria, BP<130/80 if albuminuria is present
Goal for the frail and elderly should be customized
➢ Using ACEi/ARBs for HTN and albuminuria
ACEi/ARBs dramatically affect glomerular hemodynamics
Withdrawal of ACEi/ARBs may improve eGFR, delay dialysis in stage 4-5 CKD
CV benefits of RAAS inhibition in pre-dialysis CKD is not well-defined
➢ Treating acidemia, when bicarb <22 mEq/L
➢ Treating Diabetes
Goal HgA1c ~7 but <8 for those at risk for hypoglycemia
 New diabetic drugs and CKD: SGLT-2 inhibitors
Sodium-glucose Transport Protein-
2 Inhibitors: SGLT-2 Inhibitor
➢ Inhibit SGLT-2, cause glucosuria
➢ Reduce cardiovascular risk
➢ Reduce blood pressure
➢ Reduce proteinuria and progression
of CKD Urinary Glucose
➢ Adverse effects: UTIs, genital mycotic excretion

infection, osmotic diuresis, fractures

➢ Weak glucose lowering agents:
decrease A1C by 0.5%–0.7%.
➢ Costly: 2nd/3rd line agent
 New diabetic drugs and CKD: SGLT-2 inhibitors
Meta-Analysis: SGLT2 inhibitors reduce the risk of dialysis, transplantation,
AKI, or death due to kidney disease in DM T2 (vs PBO).
Outcome Relative risk (95% CI)

Dialysis, transplantation or death due 0.67 (0.51-0.8) SGLT2 inhibitors

to kidney disease studied:
ESKD 0.65 (0.53-0.81) canagliflozin
dapagliflozin
Substantial loss of kidney function, 0.71 (0.63-0.82)
empagliflozin
ESKD, death due to CV disease or
kidney disease
4 RCTs
AKI 0.75 (0.66-0.85) N=38,723

Neuen et al. Lancet Diabet Endocrin 2019 Sep 5. Epub online

 New diabetic drugs and CKD: Summary
Decrease in A1C Advantages Disadvantages Notes on Dosing for CKD
with Monothx

SGLT-2 0.5-0.7% BP Longterm safety Dose according to

Inhibitors CV mortality not established: eGFR, but efficacy likely
CKD progr1 mycotic infxn, UTI, reduced with reduced
vol loss eGFR.
GLP-1 0.5-1.0% CV mortality Injections, GI side Only Liraglutide and
Agonists CKD progr effects, expensive Dulaglutide require no
Albuminuria2 dose adjustment*

DPP-4 0.5-0.8% Albuminuria, Expensive Only Linagliptin

Inhibitors but no improv in requires no dose
hard renal/CV adjustment*
endpoints3
1. Neuen et al. Lancet Diabet Endocrin 2019 Sep 5. Epub online * Others require dose adjustment
2. Mann, et al. N Engl J Med 2017; 377:839-848
3. Rosenstock, et al. JAMA. 2019;321(1):69-79 according to eGFR
 CKD and Anemia
The Prevalence of Anemia Rises with CKD Stage
Prevalence of Anemia (%)

I II III IV V
CKD Stages
McFarlane, et al. Am J Kidney Diseases 2008 51, S46-S55DOI: (10.1053/j.ajkd.2007.12.019)
 CKD and Anemia
Anemia is a Mortality Risk Multiplier
All Cause Death
Hazards Ratio

None Anemia CKD Anemia+ CHF Anemia+ CHF+ Anemia+

CKD CHF CKD CHF+CKD
Herzog, et al. Journal of Cardiac Failure Vol. 10 No. 6, p467-472, 2004
 Anemia and CKD: Consequences

Anemia has severe consequences in CKD:

❖ Reduced total oxygen delivery
❖ Reduced quality of life:
Fatigue, reduced exercise capacity
Reduced cognitive function
❖ Increased compensatory cardiac output
❖ Progressive cardiac and therefore renal damage
❖ Left ventricular hypertrophy
 Anemia and CKD

Mechanisms:
a) Erythropoietin deficiency---Epo enhances maturation of
erythroblastic cells and prevents apoptosis of marrow cells.
b) Iron and Functional iron deficiency
c) B12, Folate deficiency
d) Blood loss---phlebotomy and blood trapping in dialysis circuit
e) Shortened RBC survival
f) Uremia induced inhibition of erythropoiesis
g) Hyperparathyroidism-- bone marrow fibrosis, PTH-inhibited Epo
synthesis
 Anemia and CKD

Case study: Mr. D is a 55 yo man with DMT2, stage 3 CKD, and chronic
uninfected non-healing wounds. Labs: Hgb 10, ferritin 400 and TSAT
19%. He complains of fatigue.

What would be the LEAST appropriate next step in

management?
A. Start ESA injections
B. Stool testing for occult blood
C. Check B12 and Folate levels
D. Check absolute reticulocyte count
E. Start iron supplementation
 Anemia and CKD: pathophysiology
Hepcidin and Epo are central to hematopoietic balance
Metabolized or
excreted hepcidin

Transferrin

Figure adapted from: JASN October 2012, 23 (10) 1631-1634

 Anemia and CKD: pathophysiology
CKD disrupts hematopoietic balance

Hepcidin accumulates

Transferrin Epo deficiency

Loss of functional iron Uremic inhibitors

Shortened RBC survival

Figure adapted from: JASN October 2012, 23 (10) 1631-1634

 Anemia and CKD: Management
Male: Hgb<13 g/dl or Female: Hgb <12 g/dl

Rule out Non-Renal Cause of Anemia

CBC, Abs Retic, Ferritin, TSAT,
Vit B12, Folate, Stool testing for blood

TSAT <30% and Ferritin <500 ng/ml?

YES NO

Iron/Functional Iron Deficiency Epo Deficiency

Provide po/IV iron Consider ESA if Hgb <10

Target Hemoglobin 9-11.5 KDIGO Practice Guidelines for Anemia in Chronic Kidney
Disease. Kidney International Supplements (2012) 2, 331–335
 Anemia and CKD: ESA and target Hgb
TREAT rct: Using ESA in CKD to achieve target
Hgb 13 increases risk of stroke
Darbo, Target PBO, Darbo if
Hgb 13 Hgb<9
Achieved Hgb 12.5 10.6
HR for CV events 1.05 (p=0.4)
HR for Death 1.05 (p=0.48)
HR for ESRD 1.06 (p=0.29)
HR for Stroke 1.92 (p <0.001)
N=4038
Pfeffer et al. N Engl J Med 2009; 361:2019-2032
Type 2 diabetic, egfr 20-60
 Anemia and CKD: Key Messages

Anemia is modifiable risk factor for CV morbidity, mortality and

poor quality of life
1. Target Hgb 9-11.5 g/dL
BUT individualize targets for younger, active, or symptomatic patients
2. Rule out iron/functional iron deficiency first
3. Iron can raise Hgb, delay/prevent the need for ESAs, or lower ESA doses
4. Avoid IV iron in setting of systemic infection
5. Adjust ESA dose according to symptoms, use lowest possible ESA
6. If iron stores are adequate, start ESA once Hgb <10
7. Do not use ESAs to target Hgb > 13; risk for stroke, HTN, CV events*
8. Use caution with ESAs in active malignancy, if cure is anticipated
*Palmer et al. Ann Intern Med. 2010;153:23-33
 CKD: Nephrology Referral
All of the below should seek nephrology evaluation EXCEPT:
A. Initial visit: eGFR 25 & 3 months later: eGFR 28
B. Initial visit: eGFR 50 & 3 months later: eGFR 50, both dates the
ACR < 30 mg/g
C. Initial visit: eGFR 54, & 3 months later: eGFR 44 confirmed with
repeat eGFR 45
D. Initial visit: ACR 450 & 3 months later: ACR 400, eGFR 90
E. Initial visit: eGFR 90 & 3 months later: eGFR 90 with recurrent
extensive nephrolithiasis
 CKD: When to Refer to Nephrologist?

KDIGO 2012 Guidelines for Referral to Nephrology

AKI or abrupt sustained fall in GFR (>25%)
GFR <30 ml/min/1.73 m2 (GFR categories G4-G5)
Significant albuminuria (ACR >300 mg/g, PCR >500 mg/g)
Progression of CKD (a sustained decline in eGFR of >5 ml/year)
Urinary red cell casts not readily explained
Persistent abnormalities of serum potassium
CKD and HTN refractory to treatment with 4 or more
antihypertensive agents
Recurrent or extensive nephrolithiasis
Hereditary kidney disease
Kidney Disease: Improving Global Outcomes (KDIGO) CKD Work Group. Kidney Int Suppls. 2013;3:1-150
 CKD Symptoms Affecting QOL

How does CKD feel?

• Pain • Anorexia/Nausea
• Pruritis • Constipation/Diarrhea
• Depression/Anxiety • Chest pain
• Sleep Disorders • DOE
• Impaired Physical Functioning • Edema
• Loss of Energy • Impact of dialysis: cramps, access
• Sexual Dysfunction pain, lightheadedness, fatigue, missed
• Cognitive Dysfunction meals, travel logistics……

Data shows that QOL scores decrease as CKD progresses.*

* Mujais et al. CJASN August 2009, 4 (8) 1293-1301
 CKD, QOL, possible therapies
Selected QOL Elements Treatment examples
Depression/Anxiety CBT, Pharmacotherapy (SSRI)
Pain Pain management, Exercise, Massage therapy,
Acupuncture, Topical analgesics, CKD-MBD treatment
Sexual Dysfunction PDE-5 inhibitor (minimal data in ESRD)
Fatigue Evaluate for: OSA, Anemia, Malnutrition
Pruritis Emollients, UBV phototherapy, Gabapentin, CKD-MBD
Sleep Disturbance Sleep hygiene, sleep study, RLS treatment (Ropinirole,
Gabapentin), melatonin, CKD-MBD treatment
Nausea/anorexia Evaluate for: uremia, gastroparesis
Bottom line: You won’t know unless you ask.
Treatment takes an interdisciplinary effort
 ESRD and Collaborative Care
Final Case: SS is a 75 yo AA woman with hx DM Type II, dementia, CVA and CKD
stage V who lives independently. She has had repeated hospitalizations due to
weight loss, falls and difficulty completing her ADLs. Patient’s family is adamant
that she start dialysis as soon as is necessary.
You, her PCP, are asked to attend the family meeting. What do you
advise with regard to ESRD and starting dialysis?
A. Let’s leave it to the Nephrologist and take their lead either way.
B. This is mostly uremia, and dialysis should improve her overall
functional status.
C. The patient has a grim prognosis and dialysis may not improve
her quality of life
D. A and B
 ESRD and Collaborative Care

Problems with hemodialysis in the elderly:

➢ Fistulas that do not mature
➢ Increased Hospitalizations
➢ Lower albumin
➢ Increased risk for depression
➢ Increased risk for adynamic bone disease
➢ Increased sensitivity to volume shifts: sub-
endocardial ischemia
➢ Greater time to “recover” from the dialysis
treatment
 ESRD and Collaborative Care
Life expectancy on dialysis depends on your frailty phenotype

-- Healthy
-- Vulnerable
-- Frail

The Journals of Gerontology: Series A, Volume 67,

Issue 12, December 2012, Pages 1400–1409
 ESRD and Collaborative Care
Dialysis Does not Prevent Functional Decline in Nursing Home Patients
Change in Functional Status after Initiation of Dialysis in Nursing Home Patients

--61%-- 39%
N: 3702
Avg Age: 73

--87%-- 13%

Tamura, et al. N Engl J Med. 2009 Oct 15; 361(16): 1539–1547.

 ESRD and Collaborative Care
Maximum conservative therapy may lead to comparable number of hospital
free days as hemodialysis in the elderly with high comorbidity (Observ. study)
Distribution of days survived: MCM vs HD

N 202
Age >70

Carson, et al. CJASN October 2009, 4 (10) 1611-1619

 ESRD and Collaborative Care
Non-Dialysis Maximum Conservative Management is active treatment with:
• Advanced care planning , implementing patient’s goals
• Management of anemia, bone disease, fluid balance, acidosis, MBD
• Discontinue Acei
• Low protein diet (0.8g/kg)
• Candidates
- stage V CKD
- typically older than 75 years
- have high level of comorbidity
- significantly impaired functional status
- serum albumin <2.5 g/dl
 Summary: Improving Outcomes in CKD
1. Progression of CKD can be delayed by:
a. Management of HTN
b. Use of ACEi/ARBs
c. Treatment of Acidemia
d. Control of Diabetes
2. New diabetes drugs (SGLT-2 inhibitors, GLP-1 agonists, DPP-
4 inhibitors) demonstrate some promising renoprotective
benefits but are still 2nd/3rd line agents due to cost and safety
concerns.
3. Anemia in CKD is multifactorial, but address iron
deficiency/functional iron deficiency before initiating ESA
therapy.
 Summary: Improving Outcomes in CKD
4. Advanced CKD and ESRD have a comparable and profound
effect on QOL. Many symptoms like depression, pain and
sexual dysfunction can be treated with interdisciplinary effort.

5. The elderly (>65yo) is the fastest growing ESRD

population and the most susceptible to adverse effects of
dialysis. Longevity on dialysis is a function of frailty.

6. Frail elderly ESRD patients may not substantially benefit

from dialysis in terms of QOL and longevity. Non-dialysis
“maximum conservative therapy” should be offered. PCP
involvement in defining goals of care is critical.
Thank you!