Reducing risk of CKD progression Arasu Gopinath, MD Relative risk - - PowerPoint PPT Presentation

Reducing risk of CKD progression

Arasu Gopinath, MD

Relative risk of outcomes in CKD

Delaying CKD progression

• BP control and RAAS blockade
• All adults with UACR < 30 mg/g, goal BP < 140/90
• All adults with UACR > 30 mg/g, goal BP < 130/80
• ACEI or ARB in all adults with UACR > 300 mg/g
• ACEI or ARB in diabetics with UACR > 30 mg/g

Delaying CKD progression

• Limiting protein intake

~ 0.8 g/kg/day in CKD 4-5 categories ~ not to exceed 1.3 g/kg/day in order to delay CKD progression

• Minimizing AKI

~ avoiding NSAIDs and other toxic drugs (Lithium), avoiding combination of 3+ drugs that impair renal autoregulation, avoiding herbal products and hypotension Contrast induced nephropathy

• Stop nephrotoxic agents prior to contrast
• In GFR < 60 ml/min, avoid high osmolar contrast, use lowest dose possible, hydrate

with saline and repeat labs in 48-96 hours.

• Avoid phosphate containing bowel preparations
• Glycemic control

~ A1c < 7

• Salt intake

~ < 2.0 gram of Sodium/day, i.e. < 5 g/day of salt

• Hyperuricemia

~ insufficient evidence

• Lifestyle changes

~ exercise 30 minutes 5 x week, goal BMI 20-25, quit smoking

NSAIDs in CKD

• Impair glomerular autoregulation/ ATN
• Resistant hypertension and make anti hypertensives

less effective

• Acute interstitial nephritis
• Nephrotic syndrome (Minimal Change Disease and

Membranous Nephropathy)

• Acute papillary necrosis and hematuria
• Edema/ heart failure
• Distal RTA and nephrolithiasis
• Hyperkalemia
• Chronic use associated with CKD and its progression

CKD Development Team

• Co-Chairs
• Wayne Cannon
• CKD Medical Director – Arasu Gopinath
• PCCP Operations Director – Sharon Hamilton
• Regional specialty representation (North, Central, South, SW) – generally the Dialysis Medical Director (nephrologists)
• Harry Senekjian – Northern Region
• Jeff Barklow – Central Region
• Terrence Bjordahl – Central Region
• Terry Hammond – South Region
• Carlos Mercado – SW Region
• PCP representation
• Jeff Twitchell – Central Region (North Salt Lake)
• Roy Gandolfi – Affiliates / SelectHealth
• Tom Clark – North Region
• Paula Haberman – Central Region (South Salt Lake)
• PCCP Guidance Council: Michael Visick, Donna Barhorst, Mark Lewis, Anne Pendo, Tim Johnson, Gordon Harkness, Mark Greenwood,

Marty Nygaard ( PCCP Guidance Council but they do not attend)

• Dialysis Svcs Ops Director – Ray Morales
• Dietician – Joy Musselman
• Compliance – Mary Zollo
• Integrated Care Management – Teresa Garrett
• Education team - Pending
• Pharmacist - Tyson Brooks
• Analyst – Jonathan Anderson
• Data Manager - Brett Reading

The IHC database

CKD risk chart by region

CKD risk chart by physician

CKD CPM

CKD Flash Card

Patient handouts in iCentra

Likely prompts in iCentra/ CPM

Questions

• 1. Risk for progression of CKD is highest in the 60 year
• ld non diabetic male, when
• a. eGFR is 70 and UACR is 100 mg/g
• b. eGFR is 60 and UACR is 500 mg/g
• c. eGFR is 50 and UACR is 20 mg/g
• d. eGFR is 40 and UACR is 10 mg/g

Questions

• 2. Avoiding NSAIDs in CKD is part of the Choosing

Wisely campaign. NSAIDs can worsen CKD in all of the following ways except:

• a. Acute interstitial nephritis
• b. Nephrotic syndrome
• c. Resistant hypertension
• d. Distal RTA
• e. Proximal RTA

Questions

• 3. Which of the following interventions is least

likely to retard progression of CKD?

• a. Limit protein intake to approx 0.8 g/kg/day in

CKD G4

• b. Correct serum Bicarbonate to greater than 22
• c. Limit salt intake to less than 5 grams a day
• d. Control Uric acid level to less than 6.5

Questions

• 4. Which of the following combinations is likely to have

the most impact on proteinuria?

• a. ACEI + Thiazide
• b. ACEI + ARB
• c. ACEI + DRI (Aliskiren)
• d. ACEI + ARA (Spironolactone)

Questions

• 5. All of the following are recommended interventions

to reduce contrast induced nephropathy in CKD G3-5 except?

• a. Stop Metformin and diuretics temporarily
• b. Avoid isosmolar contrast agents
• c. Hydrate with saline pre and post contrast
• d. Measure Creatinine/ eGFR 2-3 days post contrast