Chronic Kidney Disease: A Silent Epidemic Case Review

1
Chronic Kidney Disease A Silent Epidemic (Case
Review)

• Naima Ogletree, MSN, APRN, BC
• Nephrology Hypertension
• Henry Ford Health System

2
Case Study

• History of Present Illness
• Mrs. A is a 50 year old African American female
• She is seeking care from a new physician
• No complaints today
• Compliant with her previously prescribed
  medications regularly
• Remainder of her HPI is unremarkable
• Past Medical History
• Type 2 diabetes mellitus (of 5 years duration)
• hypertension (of 10 years duration)
• Obesity
• No history of stroke or CV disease. The remainder
  of her past medical history is unremarkable.

3
Case Study

• Past Laboratory Studies(4 months prior to this
  visit)
• Serum chemistries, cholesterol indices, and
  hematological studies (complete blood count) were
  normal at that time.
• BUN 18 mg/dL, SCr 1.8 mg/dL
• Hb Alc was 6.3
• UA normal pH, normal specific gravity, negative
  glucose, negative bilirubin, negative ketones, 1
  protein, negative leukocyte esterase, and
  negative nitrite
• EKG 1 year ago, which is normal

4
Case Study

• Social History
• Married, with 3 children
• Works as an administrative assistant
• She is a smoker
• Review of Systems Ophthalmology annually
• Medications
• Metformin 1 GM twice a day, Losartan 50 mg PO
  once QD

5
Case Study

• Physical Examination
• BP140/88, WT. 170 pounds, height 5'2
• Remainder of her examination (including eye,
  cardiovascular, and neurologic exams) is
  unremarkable
• The PCP orders routine labs and reviews them with
  her one week later

6
Case Study Labs one week ago

• CBC, NA, K, CO2, CL, -NL
• UA protein 1, otherwise WNL
• BUN 18 mg/dL
• Serum Creatinine 1.9 mg/dL
• HbA1c 7.0
• Serum cholesterol 220 mg/dL, Triglycerides 200
  mg/dL, LDL 110 mg/dL, HDL 44 mg/dL

6
7
Issues

• Does she have CKD?
• Stage of CKD
• How would you code her disease?
• What is her risk of progression of kidney
• disease?
• How can we safely slow her progression of kidney
  disease?
• What are her cardiovascular risks?
• How do we manage this pt?

8
Case Study 2

• This is a 70 y.o. AAF who was referred for
  evaluation of an ? SCr
• Records Baseline SCr (2001) at that time was 2.1
  mg/dL w/ GFR of 28
• Upon referral to the department her initial BP
  reading was 139/79 mmHg

9
Case review

• Medication List
• Simvastatin 20 mg ONCE DAILY
• Diltiazem 240 mg ONCE DAILY
• HCTZ 25 mg ONCE DAILY
• Losartan 100 mg ONCE DAILY
• Metoprolol 200 mg TWICE DAILY
• ASA 325 mg ONCE DAILY
• Aleve OTC as needed (she takes at least once a
  month).

10
Case Review Risk Factors

• Cigarettes 40 pk-yrs
• PMH
• PAD
• High cholesterol
• NSAID use
• Hypertension
• Uncontrolled SBP due to non-compliance with drug
  regimen secondary to non-adherence to her
  anti-hypertensive regime
• Could not afford medications
• Relied heavily on sample medications

11
Case Review

• Kidney US
• Lt 9.6 cm Rt 9.4 cm
• UA dipstick gt300 mg/dL (06/01)
• PCP Tx ACEI
• Angioedema
• ARB substitution

12
Case Review

• She was referred to the CKD clinic in October
  2004 for further management of her chronic kidney
  disease. She was asymptomatic for uremic
  symptoms. BP at time of referral 116/68.

13
Case Review

• Lab review There was a slow progressive decline
  in her renal function
• BUN/Cr (46/3.66)
• UPC 0.38 (2004)
• GFR 15 ml/min/1.73 m² (Stage 4)
• K 5.3 meq/L
• Lipid panel TC 128 TG 61 HDL 46 LDL 70
• Hgb/Hct 9.7/29.0
• P 4.6 / PTH 128 / 1,25(OH)2D 45, 25(OH)D 25Ca x
  P 42.32

14
Case Review

• Interventions
• Attend the CKD education class (modality)
• Placed on individualized renal diet (low Na, low
  K, low phosphorus) by renal dietician
• Monthly darbepoetin alfa (Aranesp) 60 mcg, sub-Q,
  initiated (10/04), with prn iron, p.o.
• Vascular Surgery referral
• AVF construction (02/15/05)

15
Case Review

• Evaluated by the renal transplant team on April
  25, 2005. Placed on waiting list. Also has a
  willing living related donor whose work up is in
  progress.
• Phosphorus binding agent started in Oct. 2004.
• Started on monthly ergocalciferol for her
  hypovitaminosis D in Feb. 2005.
• Referred to the renal dietician for quarterly
  assessments.
• Fistula was cleared for use in March 2005.
• Deemed a suitable candidate for renal transplant
  by the transplant surgeon May 2006.

16
Case Review

• Pt has remained clinically stable. Her most
  recent office visit was July 13, 2007. Her BP was
  124/64. She remains asymptomatic for uremia,
  normokalemic, and euvolemic. She has a patent AV
  fistula whenever the need arises. Follows
  routinely with renal dietician. She does not
  require HD at this time

17
Case Review

• Current lab data She is noted with stable renal
  function BUN/Cr (59.4/3.85). Normal protein
  excretion rate. ProCr ratio was 0.22 mg/dL. Her
  estimated GFR was 14 ml/min/1.73m² (stage 5).
  Potassium 4.9 Lipid panel Total-C 137 TG 76
  HDL 51 LDL 71. PTH 83 Vit D 1,25 29, VIt D
  25 56, Ca P 39.6 Hgb/Hct 11.5/33.0

18
Case Review

• Meds simvastatin 20 mg QD, diltiazem 240 mg BID,
  furosemide 40 mg BID, losartan 100 mg QD,
  calcitriol 0.25 mcg QD, clonidine 0.1 mg BID, ASA
  81 mg QD, monthly Aranesp per protocol

19
Case Review Discussion

• Noted with stable renal function
• Asymptomatic for uremia. Has not required RRT in
  5 years
• Permanent access placed in timely manner
• All therapeutic targets have been met
• Active vitamin D sterol initiated- PTH83 pg/mL
  (Goal lt150)
• Treated with binder- Phos 4.4 mg/dL (Goal
  3.5-5.5)

20
Case Review Discussion

• No proteinuria - maintained on anti-RAAS therapy
  for renal preservation
• Ca x P product 39.6 (Goal lt55)
• Cholesterol optimally controlled LDL 71 TG 76
  (Goal LDLlt100, TG lt150)
• Anemia corrected. Hgb within target range (11.4)