world kidney day celebrations 2024.pptxpptx

equitable renal health for all -role of primary care physician

1. EQUITABLE RENAL HEALTH FOR ALL -ROLE OF PRIMARY CARE PHYSICIAN DR. M. RANJANEE M.D.(GEN MED) D.M. NEPHROLOGY (SGPGIMS),FASN ,CHS,FIMSA SENIOR CONSULTANT NEPHROLOGIST APOLLO HOSPITALS , CHENNAI 3/13/2024

2. WORLD KIDNEY DAY 2024 “EQUITABLE KIDNEY HEALTH FOR ALL” 3/13/2024

3. PRESENTATION OUTLINE PHYSICIAN –NEPHROLOGIST LINK NEED TO LIAISON PHYSICIAN’S ROLE IN CKD ROLE IN OTHER CONDITIONS 3/13/2024 3/13/2024

4. IMPORTANT LINK Jack of all trades Community Triage Rapid screening of abnormal from normal Can think out of the box better Holistic approach Doctor-patient bond stronger largely independent time v/s fees –cost effectiveness Master of one Special/at risk population less scope identify problem, its extent and manage the affected group Narrow/limited vision targeted individual approach Liaison between physician and patient depends on referral mostly time v/s fees –cost effectiveness PRIMARY CARE PHYSICIAN NEPHROLOGIST 3/13/2024

5. Need for LIAISON Huge CKD burden and less than 10% of general clinic patients are screened for CKD in its early stages Serum creatinine- inaccurate marker Only < 1/4 of people with identified CKD get an ACEI DM / HTN make up 40% of patients requiring dialysis 20-50% of patients start dialysis without prior exposure to nephrologists Change in risk factors ,habits demand time, good rapport and sincere effort 3/13/2024

6. Need for LIASION cont………………… No / delayed referral- more complications complete remission unlikely and mostly only palliative care possible limited time frame for renal recovery of 3 months chances of irreversibility despite effective therapy renal medicine as curative medicine not yet fully developed Physician integral part of Govt. health policies and National programmes 3/13/2024

7. Observational Studies of Early vs. Late Nephrology Consultation Chan M, et al. Am J Med . 2007;120:1063-1070. http://download.journals.elsevierhealth.com/pdfs/journals/0002-9343/PIIS000293430700664X.pdf KDIGO CKD Work Group. Kidney Int Suppls . 2013;3:1-150. 3/13/2024

8. Benefits of symbiosis- Better understanding of the disease and better care Avoid complication and postpone if not prevent CKD Ensures continued care in the setting of chronic nature of the illness Knowledge of nephrology practices for a physician handy and is must Physician does no harm before doing good “Nephrologist rarely eyes different things but eyes common things differently” enhances physician-specialist interaction – scope for mutual growth and knowledge 3/13/2024

9. Referral to nephrologist Persistently deranged RFT eGFR declines of >4 mL/min/1.73 m2 /yr from any cause Urinary abnormality –protein/RBCs/WBCs/casts Persistent asymptomatic isolated microscopic hematuria Persistent proteinuria oliguria Nephrotic picture USG- malformation/size discrepancy/polycystic/ calculi /obstruction Pediatric age group Pregnancy with UTI/HTN/ Proteinuria Stage III CKD Difficult to treat HTN 3/13/2024

10. Role in CKD 3/13/2024

11. Primary care providers – First line of defense against CKD Primary care professionals can play a significant role in early diagnosis, treatment, and patient education Therapeutic interventions for diabetic CKD are similar to those required for optimal diabetes care Control of glucose, blood pressure, and lipids A greater emphasis on detecting CKD, and managing it prior to referral, can improve patient outcomes CKD is Part of Primary Care

12. India: Kidney disease burden Population of around 1.34 billion Prevalence of CKD- 800 / million population Age adjusted rate incident rates of ESRD- 232 / million population India currently has 1000 nephrologists 710+ HD units with 2,500+ dialysis stations and 4,800+ patients on CAPD CKD – costly treatment Indian J Nephrol .2015 May-Jun; 25(3): 133–135 . 3/13/2024

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14. RISK FACTORS FOR CKD Diabetes Hypertension Age , Family H/o Kidney Disease Systemic Infections Recurrent UTI Urinary Stone Disease Loss of Renal mass Neoplasia of any part Nephrotoxic Drugs (NSAIDs) 3/13/2024

15. HYPOTHESIS Nephron number Solute load Solute load per nephron Glomerular pressure (P ) Glomerular size (S) Short-term Long-term Glomerular injury Nephron number Kidney disease initiation or progression Hyper filtration ( SNGFR) Restore solute load per nephron Maintain solute concentration “Adaptive” “Maladaptive” 3/13/2024

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17. Smoking and kidney injury Role in the initiation and progression of diabetic nephropathy both in type 1 and 2 diabetics aggravates insulin resistance Smoking > 20cigarette/d had 1.6 fold higher prevalence of microalbuminuria and 3.7 fold higher prevalence of macroalbuminuria than never smokers JASN2002 R isk factor for the initiation of ischemic nephropathy and for the progression of hypertensive nephropathy ,IgAN ,lupus nephritis and ADPKD Increased risk of renal cell carcinoma 3/13/2024

18. Alcohol and kidney injury Nephromegaly – cell hypertrophy and proliferation Hyponatremia, hypokalemia Diuretic effect Metabolic acidosis AKI More severe dyselectrolemia expansion of ECF-HTN risk Depletion of magnesium, phosphate and calcium Risk of hyperuricemia and gout attack Acute alcoholism Chronic alcoholism 3/13/2024

19. Christine K. Abrass JASN 2004;15:2768-2772 3/13/2024

20. Obesity and ckd cont…………… Modifiable risk factor for CKD Glomerulomegaly and focal sclerosis on renal biopsy Hyperfiltration and glomerular hypertension leads to decrease in GFR and proteinuria Sleep apnoea is prevalent in CKD and obesity GFR estimation is not perfect(CG and MDRD not suitable) 3/13/2024

21. Obesity and ckd cont…………… BMI –correlates with subcutaneous fat rather than visceral fat Increased WHR (0.76 in women, 0.68 in men) reflect both increase in visceral fat and relative lack of gluteal muscle problems with dialysis access, difficult peri transplant period Weight loss and ACEI offer benefit 3/13/2024

22. Dyslipidemia In patients with ESRD , clear elevation of both TC and LDL-C levels & Plasma Lp(a) levels ( delayed clearance ) highly atherogenic lipid profile Approximately 50% of HD patients and 70% of PD patients demonstrate dyslipidemia. GFR TGL PROTEINURIA HDL TGL,TC ,LDL HDL 3/13/2024

23. Hyperglycemia and ckd 3/13/2024

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25. Natural History of Type II DM Far commoner than Type I Long asymptomatic phase HTN, nephropathy & retinopathy often exist at time of diagnosis Degree of proteinuria correlates with general vascular risk and 20x CKD risk 3/13/2024

26. Imp. of Albuminuria in CKD

27. Urate nephropathy Acute uric acid nephropathy Familial juvenile hyperuricemic nephropathy Hyperuricemia and ckd 3/13/2024

28. Multiple direct and indirect effects of thyroid hormone on GFR. Laura H. Mariani, and Jeffrey S. Berns JASN 2012;23:22-26 3/13/2024

29. Hypothyroidism and ckd 3/13/2024

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32. Anemia in CKD: Effects on the CV System Reduced Hemoglobin Reduced O2 Delivery Increased Cardiac Workout Dilated Cardiomyopathy - LVH Ischemic Heart Disease Congestive Heart Failure Angina Pectoris Myocardial Infarction 3/13/2024

33. Hypertension and ckd Arterial hypertension - independent risk factor for renal-disease progression independent risk factor for LV hypertrophy, cardiac failure, and symptomatic IHD. systolic BP or increased pulse pressure predict cardiovascular events, whereas diastolic blood pressure has an inverse relationship Better control of systolic blood-pressure level translates into slower GFR decline. 3/13/2024

34. Stages of Chronic Kidney Disease: A Clinical Action Plan Stage Description GFR (ml/min/1.73 m ) > 90 Action 2 At Increased Risk Screening, ( CKD Risk Factors) CKD Risk Reduction 1 Kidney Damage with Normal or GFR > 90 Diagnosis and Treatment, Treatment of Comorbid Conditions, Slowing Progression, CVD Risk Reduction Estimating Progression 2 3 4 5 Kidney Damage with Mild 60-89 30-59 15-29 GFR Moderate GFR Severe GFR Kidney Failure Evaluating and Treating Complications Preparation for Kidney Replacement Therapy Replacement, <15 or Dialysis if Uremia Present 3/13/2024

35. Optimal CKD Care Early Detection of CKD Interventions that delay progression Prevention of uremic complications Modification of comorbidity Preparation for RRT ACE inhibitors BP control Malnutrition Anemia Cardiac disease Vascular disease Education Informed choice of RRT Timely access Timely RRT initiation RRR dialysis Blood sugar control Protein restriction ? Osteodystrophy Acidosis Neuropathy (in diabetics ) Retinopathy (in diabetics ) Pereira, Nephrology Forum, Kid Int 2000, 57:351-365 3/13/2024

36. Primary Prevention ( KDIGO 2017) Smoking cessation, exercise, dietary salt reduction & weight loss at all CKD stages Control of hypertension to usual goals or lower to slow CKD progression Convincing role of aspirin in cardiovascular risk reduction in individuals with eGFR < 45 ml/min/ 1.73m2 BP control is more important than the means used to achieve it 3/13/2024

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38. Why refer ? Management of complications – anemia, MBD, CVD worsening proteinuria , metabolic acidosis Preparation for RRT-AVF creation , pre-emptive transplant Difficult to control hypertension – Need higher doses of diuretics for same effect Decrease the need for insulin , OHAs –need modification As disease progresses, need more time and attention from doctor –cost effectiveness 3/13/2024

39. Who is to be tested for CKD ? Regular testing of people for CKD a must for All Diabetics whether Type 2 or Type 1 All Hypertension patients – SHT or DHT Patients having a relative with kidney problem All patients of Cardiovascular disease Pts with Obesity, Metabolic syndrome, smokers 3/13/2024

40. Investigating CKD 3/13/2024

41. Blood Urea v/s Sr. Creatinine Parameter Blood Urea (BUN) Serum Creatinine As measure of GFR Only half the GFR Nearly 95% Calculation of eGFR Not useful It is the parameter Day to day variance More Less Pred. of improvement Changes late Changes soon Affect of meat diet Yes; affected Yes; affected Volume status of pt. Affects very much Not so much Upper GI bleeding Increases it Not affected Corticosteroid Rx Increases it Not affected 3/13/2024

42. Why eGFR ? Why not Creatinine ? Age Gender Race SCr (mg/ dL ) eGFR (ml/min/1.73 m 2 ) CKD Stage 20 M W 1.3 91 1 20 M B 1.3 75 2 20 F W 1.3 56 3 55 M W 1.3 61 2 55 F B 1.3 55 3 85 F W 1.3 41 3

43. CKD STAGE TESTS TEST FREQUENCY 1 BP,LIPID,GLUCOSE RFT, S. ELECTROLYTES, eGFR URINE ANALYSIS 6-12 MONTHS 2 ABOVE + URINE SPOT PCR 6-12 MONTHS 3A LIPID,GLUCOSE, RFT, S.ELECTROLYTES,eGFR BP AND UPCR 6 MONTHLY 3 MONTHLY 3B LIPID,GLUCOSE, RFT,S.ELECTROLYTES eGFR, BP,UPCR CBC ,IRON INDICES BASELINE Ca,P,ALP,25(OH) D 3 MONTHLY 1-3 MONTHS 3/13/2024

44. Lifestyle & Dietary Potential Dietary Increase fitness – – – – – – Restrict dietary salt Fruit and vegetables Mediterranean diet Dietary fibre Improve blood pressure Improve glycemic control Improve survival, vascular health, etc. Reduce albuminuria Calorie control Limited cola beverages Physical exercise Weight reduction Smoking cessation Alcohol reduction What should we do? What can we do? KDIGO Diabetes Conference | February 5-8, 2015 | Vancouver, Canada 3/13/2024

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46. Treatments to Slow the Progression of Chronic Kidney Disease in Adults Diabetic Kidney Disease Nondiabetic Kidney Disease Yes a Strict glycemic control NA ACE-inhibitors or angiotensin- receptor blockers Yes Yes (greater effect in patients w ith proteinuria ) Strict blood pressure C ontrol <1 30 / 8 mm Hg Yes Yes <1 3 0/ 8 mm Hg Dietary protein restriction 0.6-0.8 g/kg/d Uncertain Uncertain 0.6-0.8 g/kg/d Lipid-lowering therapy Probable Probable LDL<100 mg/dl LDL<100 mg/dl a Prevents or delays the onset of diabetic kidney disease . 3/13/2024

47. Hypertension Guidelines up to 201 7 CHEP AHA ESH/ESC 2013 KDIGO 2015 2017 140/90 140/90 130/80 & JNC2014 201 7 140/90 130/80 140/90 Non-proteinuric CKD 1 30/80 1 3 0/ 8 1 3 0/ 8 140/90 140/90 140/90 Proteinuric CKD Diabetic, non- proteinuric CKD Diabetic, proteinuric CKD 130/80 150/90 1 30/80 1 4 0/90 140/90 130/80 Elderly 140/90 Individualized 3/13/2024

48. Hyperuricemia management Uric acid lowering is associated with significant fall in serum creatinine and an increase of the eGFR. - Wang et al, J Ren Nutr 2013 Febuxostat (upto 240 mg/d)- renal safe and more effective than allopurinol ( 100-300 mg /d) Target uric acid – below 6 mg % 3/13/2024

49. HTN management Diabetic with proteinuria- ACEI or ARB Cilnidipine, DHPs Prostatomegaly- add alpha1 blocker CAD- cardio selective beta blocker metoprolol ,bisoprolol and carvedilol useful intrinsic sympathomimetics to be avoided Pregnancy – acute case- Labetolol, NTG chronic- hydralazine ,methyldopa,DHP AVOID BETA BLOCKERS,ACEI/ARB ,DIURETICS Hyper uricemia- Losartan 3/13/2024

50. ACE INHIBITORS Secondary prevention in pts with h/o CVD Proteinuria reduction by 30-40% The antiproteinuric response in the first 2–3 months predictive of the long-term renoprotective effect & reduced rate of CKD progression Preferential combination with a diuretic or a CCB (DHPs) combination with ARB not advised Caution when GFR <22ml/min, reno vascular disease and hyperkalemia Repeat RFT after 4 weeks of therapy initiation 3/13/2024

51. Hyperglycemia management HbA1C <7% (ada2018) 3/13/2024

52. eGFR (ml/min) >60 30-59 15-29 Metformin <15 dialysis) Glimepiride Gliblenclamide Pioglitazone Vildagliptin Sitagliptin Saxagliptin Linagliptin Exenatide Liraglutide Insulin Dapagliflozin Canagliflozin Empagliflozin 3/13/2024

53. Lipid control Based on the SHARP findings, all non-dialysis CKD patients with or without overt CVD should receive a statin as primary prevention for CVD, but not for protection against progressive CKD. Based on post hoc analysis of JUPITER trial, for primary prevention of CVD, patients with higher LDL concentrations (> 100 mg/ dL ) & with rapidly progressing GN , should probably receive a statin Target LDL-C <100 mg/ dL and BMI 18.5–24.9 kg/m2 3/13/2024

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55. For secondary prevention of cardiovascular risk in all CKD stages 1-5 renal safe - a torvastatin and fluvastatin Acc to KDOQI, combination of statin & fibrates safe Ezetimibe as second line drug along with statin in CKD Monitor CPK, LDH , transaminases Lipid control cont…………… 3/13/2024

56. SECONDARY PREVENTION Patients with CKD stages 1-5; with a history of chronic stable angina, ACS, MI, stroke, PVD or who undergo surgical or angiographic coronary revascularization, should be prescribed aspirin, an ACE inhibitor, a beta-blocker, and an HMG–Co A reductase inhibitor unless contraindicated as per NICE Guidance (1B) Aspirin and clopidogrel may be indicated for up to 12 months post angioplasty and stenting and in non-ST elevation MI (2C) 3/13/2024

57. VACCINATION 3/13/2024

58. VACCINATION cont…………. QUADRIVALENT INFLUENZA (inactivated) – 0.5 ml IM annually VARICELLA ZOSTER – 2 doses IM , 1 month apart PNEUMOCOCCAL – PREVNAR 13 – single dose 0.5 ml SUBCUT------ ---- 8 weeks later – PNEUMOVAC 23 0.5 ml 3/13/2024

59. Special Scenarios 3/13/2024

60. EPIDEMIOLOGY • 5-7% of acute care hospital admissions • 30% of ICU admissions with mortality rates – 50% • AKI worsens CKD • Severe AKI requiring dialysis increases risk of developing dialysis-requiring-ESRD. • Community-acquired AKI: Volume depletion, ADRs & obstruction of the urinary tract. • Hospital-acquired AKI: Sepsis, major surgical procedures, heart or liver failure, IV iodinated contrast and nephrotoxic drugs 3/13/2024

61. Kdigo staging for aki 3/13/2024

62. IMPORTANCE OF PRIMARY CARE Prevention 2/3 rd AKI patients –already developed it by the time of hospitalization, so preventative strategies need to include a focus on primary care. Early Detection and Management High suspicion and judicious use of medications Post-AKI Care early review to assess extent of recovery longer-term monitoring to assess for CKD development or progression 3/13/2024

63. Management of fluids /blood products P ost operative states (LSCS, abdominal Sx) Acute gastroenteritis Kidney or urinary tract stone Rhabdomyolysis (earthquake, trauma) Hemolysis Assess volume status –clinical, urine output, CVP,MAP Judicious use of IV fluids Choose correct type of fluid 3/13/2024

64. Composition of balanced iv fluids 3/13/2024

65. Management of fluids /blood products cont…….. Aim/goal based fluid therapy - risk of hyperchloremic AKI Check serum albumin –esp. in nephrotic syndrome, cirrhosis Don't overload the patient Need based blood products 3/13/2024

66. Drug induced kidney injury Proton pump inhibitors- AIN ,risk of CKD NSAIDS- hemodynamic AKI, CIN,MCD, papillary necrosis, urothelial malignancy ,hyperkalemia ACEI/ ARB- avoid in perioperative period, pregnancy risk of hyperkalemia Diuretics – hypovolemia , fall in GFR role in AKI/CKD avoid thiazides when GFR< 30ml/min 3/13/2024

67. Drug induced kidney injury CONT……. Amino glycosides- concentration dependent once daily dosing advised proximal tubule injury Amphotericin –liposomal safe Cephalosporins - ceftriaxone , cefaperazone safe Penicillin- diclox, oxacillin Quinolones - moxifloxacin safe Macrolides - erythromycin, clindamycin, doxy Others- linezolid , chloramphenicol 3/13/2024

68. Drug induced kidney injury CONT……. Anti Malarials- pyremethamine , primaquine Anti TB – rifampicin , rifabutin, INH Anti Virals – efavirenz,nevirapine ,abacavir Anti Fungals- oral voriconazole , posoconazole, micafungin IV acyclovir - crystalluria Lithium – MCD, CIN, dRTA ,Hypokalemia Prior to chemotherapy – adequate hydration baseline RFT, electrolytes 3/13/2024

69. Native medications Product Active toxin Effect on kidney Origin Chinese herb (anti slimming agent) Aristolochia fangchi Nephropathy-CKD Urothelial Malignancy Balkan region Hair dye powder Para phenylene - diamine Rhabdomyolysis AKI India, Morocco Djenkol Bean Raw fruit AKI South east asia Fresh water Carp Raw gallbaldder /bile AKI,hepatic faliure Japan, South Korea, and parts of India 3/13/2024

70. Native medicatons cont…… Ginkgo biloba–induced hemorrhagic complications Glycerrhiza glabrata (licorice)- Glyrrhizic acid– ATN, hypokalemia Alfalfa or noni juice (Morinda citrifolia)– hyperkalemia St. John’s wort ( Hypericum perforatum)- for depression and anxiety- hepatic cytochrome P450 inducer 3/13/2024

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72. UTI MANAGEMENT Single episode in male UTI+ stone /anatomical abnormality UTI+ renal dysfunction Pyelonephritis –xanthomatous, emphysematous TB, fungal UTI in pregnancy Recurrent UTI Immediate referral Planned referral 3/13/2024

73. PREVENTION OF UTI MYTH – more fluid intake is beneficial Avoid constipation Avoid public toilets as far as possible. “flush before own use” Post menopausal age group- estrogen therapy Not all stone diseases need urine alkalization Urinary catheterization- only need based Timed voiding –esp. mutipara, prostatomegaly, neurogenic bladder 3/13/2024

74. Investigation / instrumentation Contrast agents – risk of contrast nephropathy Choose alternative safe procedure if unavoidable – small volume ,non ionic iso-osmolar or low osmolar agent - adequate hydration(1/2 isotonic saline with bicarb) pre and post ----best - NAC- doubtful role - baseline RFT and repeat 48 hours after - discontinue metformin NSAID, diuretic MRI – gadolinium – nephrogenic systemic fibrosis GFR< 30 ml/min 3/13/2024

75. Acid base imbalance and dyselectrolemia Interpretation of ABG Serum anion gap- “unmeasured anions” Urinary anion gap- cause of NAG metabolic acidosis Measurement of - serum and urine osmolality –hypo/hyper natremia osmolal gap (measured –calculated osmolality) Fractional excretion of sodium- cause of AKI (Urine Na / Serum Na) / (Urine Cr / Serum Cr) * 100 3/13/2024

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77. URINE EXAMINATION Measurement Lower limit Upper limit Unit Urinary Specific gravity 1.003 1.030 g/ mL Osmolarity 40 1200 m Osm/kg Urobilinogen 0.2 1.0  Ehrlich units or mg/ dL RBCs / erythrocytes 2 - 3 per high power field (HPF) RBC casts N/A 0 / negative WBCs / leukocytes 5 / negative pH 4.5 8 (unit less) 3/13/2024

78. Measurement Lower limit Upper limit Protein trace amounts Glucose N/A 0 / negative Ketones N/A 0 / negative Bilirubin N/A 0 / negative Blood N/A 0 / negative Nitrite N/A 0 / negative URINE EXAMINATION Cont………. 3/13/2024

79. Proteinuria Spot urine protein creatinine ratio –first morning sample and min 50 ml req. proteinuria > 3.5 g/24 h ~ ratio >3.5 < 0.2 g/24 h ~ ratio of <0.2 24 hr urinary protein and creatinine Urine spot ACR – microalbuminuria(UAER- 30-300 mg/d) Urine albumin by dipstix – for follow up of childhood NS Urine AFB – two consecutive days ,early morning sample Urine culture – clean catch mid-stream sample For cells /casts/ crystals- first-void morning sample 3/13/2024

80. Cardiac tests ECG not specific ECHO to see motion wall abnormality (annually) CRP Homo cysteine-AHA &ACC Cardiac enzymes -Falsely elevated Still Troponin I better than Troponin T Rising titre more important Radionuclide scan –not predictive of CAD in CKD Dobutamine stress ECHO- sensitive and specific 3/13/2024

81. Special population Extremes of age – prone for AKI Pregnancy – normal creatinine lower than adult value - BP target lower- dBP < 85 mmHg - HTN < 20 wks gestation different from HTN > 20 weeks - UTI / PIH/PPH Diabetes- eGFR> 60 ml/min- CKD(EPI) eGFR < 60 ml/min- MDRD (6 variables) 3/13/2024

82. Young hypertension <30 yrs ,> 50 years secondary hypertension- renal dysfunction , hypokalemia resistant hypertension encourage home BP monitoring - calibrate with office monitor one nocturnal reading must SPECIAL POPULATION CONT…………… 3/13/2024

83. Hurdles in effective referral 3/13/2024

84. Take Home Messages CKD is a silent killer – we need to uncover it DM most common cause of ESRD all over globe CKD - more likely CV death than progression to ESRD Prevent cardiovascular morbidity and mortality CKD progression is preventable – early screening & treatment Multi-risk factor intervention is critical Blood pressure target more important rather than means to achieve it Combinations of ACEI + ARB not beneficial rather harmful Judicious use of IV fluids ,blood products, diuretics and drugs 3/13/2024

85. Let this not happen please! Normal ESRD 3/13/2024

86. THANKS 3/13/2024