Chronic Kidney Disease (CKD) in the Hospitalized Patient

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Chronic Kidney Disease (CKD) in theHospitalized
Patient

• Catherine Staffeld-Coit, MD

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• No disclosures.

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Objectives

• Explain the scope of CKD and its stages.
• Discuss options for renal replacement therapy.
• Review commonly seen problems in renal patients.
• Explore the reasons for markedly higher incidence
  of cardiovascular disease in the renal
  population.

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Estimating Severity of CKD

• Can use many formulas.
• ALL require steady state, BUT not on dialysis.
• MDRD Calculator available _at_ many sites

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Staging of CKD
National Kidney Foundation
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USRDS Projected Growth of Prevalent Dialysis and
Transplant Populations
U.S. Renal Data System, USRDS 2008 Annual Data
Report, NIH, NIDDK, 2008
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Geographic variations in adjusted incident rates
of ESRD per million population, 2009, by HAS Fig
1.4 (Vol 2)
Adj age/gender/race ref 2005 ESRD patients.
U.S. Renal Data System, USRDS 2011 Annual Data
Report, NIH, NIDDK, 2011
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Prevalent counts adjusted rates of ESRD, by
raceFig 1.12 (Vol 2)
December 31 point prevalent ESRD patients. Adj
age/gender ref 2005 ESRD patients.
U.S. Renal Data System, USRDS 2011 Annual Data
Report, NIH, NIDDK, 2011
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Prevalent Counts adjusted rates of ESRD, by
diagnosisFig 1.14 (Volume 2)
December 31 point prevalent ESRD patients. Adj
age/gender/race ref 2005 ESRD patients.
U.S. Renal Data System, USRDS 2011 Annual Data
Report, NIH, NIDDK, 2011
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Causes of Renal Failure

• DM 30-40
• HTN 25-35
• GN
• Genetic
• Polycystic Kidney Disease
• Alports
• Obstructive nephropathy
• Drug-induced
• Unknown

U.S. Renal Data System, USRDS 2008 Annual Data
Report, NIH, NIDDK, 2008
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Adjusted all-cause mortality in the ESRD
general populations, by age, 2009 Fig 5.2 (Vol 2)
Prevalent ESRD general Medicare (non-ESRD)
patients. Adj gender/race ref Medicare
patients, 2009.
U.S. Renal Data System, USRDS 2011 Annual Data
Report, NIH, NIDDK, 2011
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FIGURE 17-15 Causes of death among U.S.
transplant recipients with a functioning graft.
CVD, cardiovascular disease.  (From U.S. Renal
Data System USRDS 2005 Annual Data Report Atlas
of End-Stage Renal Disease in the United States.
Bethesda, MD, National Institutes of Health,
National Institute of Diabetes and Digestive and
Kidney Diseases, 2005, p 152.)
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Overview of Dialysis Therapy

• Outpatient (in-center) Hemodialysis (HD)
  usually done 3 times a week. Most common type.
• Home therapies
• Daily or nocturnal HD.
• Chronic Ambulatory Peritoneal Dialysis (CAPD)
• Cyclic Peritoneal Dialysis usually performed at
  night.
• Require patient or caregiver be thoroughly
  trained to perform independently.
• Less common as in-center hemodialysis.

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Renal Replacement Therapy
NIDDK
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Renal Transplantation

• Treatment, not cure.
• Usually performed w/o nephrectomy.
• Requires lifelong immunosuppression.
• Immunos may cause side effects (DM, HTN,
  hyperlipidemia, CVD, cancer, infection).

NIDDK
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Complications of Renal Failure (partial)

• Intradialytic Hypotension (during HD)
• Malnutrition
• GI Bleed
• Nephrogenic Systemic Fibrosis
• Neurologic
• Cardiovascular disease (CVD)
• Infection
• Acquired Cystic Disease
• Anemia

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Hypotension Occurs in 20-30 of HD treatments

• Causes
• Rapid reduction of plasma osmolality causing
  extracellular water to shift into cells.
• Rapid fluid removal/ultrafiltration (UF) ofgt1.5
  L/hr.
• Poor cardiac reserve.
• Autonomic neuropathy.
• BP meds.
• Eating before or during dialysis.
• May present 1-2 hours post-treatment.
• Therapies- Volume replacement, adjust meds, UF
  slowly, check EF.

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Hypertension

• Seen in 85 of renal patients.
• Salt/water excess usual cause.
• Elevated renin secretion from diseased kidneys is
  common.

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Hypertension

• ESA side effect
• Sympathetic over activity.
• Non-compliance with meds or withholding prior to
  dialysis.
• Salt and water restriction not followed.

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MalnutritionAssociated with decreased survival

• Causes
• Drug effects.
• Chronic constipation.
• Lack of understanding of renal nutrition.
• Low income.
• Malabsorption and GI motility disorders.
• Impaired taste.
• All Patients are evaluated and followed by
  dietician in dialysis unit. CKD patients should
  receive dietary education as part of CKD care.

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GI Bleed

• Dont assume anemia is simply from CKD. Check
  iron levels and w/u when deficient.
• Gastritis - most common.
• Angiodysplasia - second most common.
• Uremic platelet dysfunction contributes to the
  severity- DDAVP can help short-term.
• If patient is possible transplant candidate, use
  WBC filter with PRBC transfusions when blood
  products needed decreases HLA antibody
  formation.

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Nephrogenic Systemic Fibrosis

• Typically starts with patients reporting swelling
  and a tight feeling in extremities.
• Skin changes may be red or dark patches, papules,
  plaques, or nodules.
• Progressing over days to weeks to inhibit flexion
  and contraction of joints contractures.
• Skin becomes woody with peu dorange
  consistency
• Lesions often symmetrical, involving LE first,
  then UE.
• Most common with GFR lt 30 and Gadolinium exposure.

From Cowper NFD/NSF Website.
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Nephrogenic Systemic Fibrosis
Raised and erythematous nodular plaques,
linear and confluent regions of fibrosis
Soft tissue swelling contractures
From nephrogenic-systemic-fibrosis.info
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Neurologic Complications of Uremia

• Uremic neuropathy is the most common neurologic
  finding.
• Uremic encephalopathy (UE) develops when GFR lt
  10 of normal.
• Rare in well dialyzed patients.
• Seizures are seen in 25 of patients with UE.
• Restless legs syndrome is reported in gt 40 of
  uremic patients.
• Myopathy, optic neuropathy and mononeuropathies
  noted.
• Hyperkalemia can cause flaccid quadriparesis.

Goetz Textbook of Clinical Neurology, 3rd ed
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Neurologic Complications of Uremia (cont.)

• Vestibulocochlear and neuromuscular junction
  disturbances can be seen in association with
  aminoglycoside atb.
• Loop diuretics can cause tinnitus.
• Amyloid fibrils (b2 microglobulin deposits) can
  cause carpal tunnel syndrome.

Goetz Textbook of Clinical Neurology, 3rd ed
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Neurologic Complications of Uremia (cont.)

• Subdural hemorrhage.
• Dialysis headaches.
• Exacerbation of migraine headaches.
• Ischemic monomelic neuropathy.

Goetz Textbook of Clinical Neurology, 3rd ed
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Neurologic Complications of Uremia (cont.)

• Dysequilibrium Syndrome
• Cerebral edema d/t rapid reduction of omolality
  during hemodialysis.
• Dialysis dementia (vascular, b2- macroglobulin).

Goetz Textbook of Clinical Neurology, 3rd ed
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Neurologic Complications of Uremia (cont.)

• Vitamin deficiency
• Water soluble vitamins dialyzed out.
• Poor nutrition common.
• Nephrology vitamins available.

Goetz Textbook of Clinical Neurology, 3rd ed
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Neurologic Complications of Uremia (cont.)

• Phenytoin has decreased plasma binding and higher
  free (active) drug.
• Check free phenytoin level.
• Usually the same loading and maintenance dosed
  used.
• Since half-life decreased, TID dosing regimen is
  favored over BID.

Goetz Textbook of Clinical Neurology, 3rd ed
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Syncope in Renal Disease

• Arrhythmias
• Intrinsic
• Electrolyte induced (K, Calcium, Mg.)
• Acidemia, or rarely alkalemia.
• Intra- or post-dialytic hypotension.
• Common causes occur commonly.
• Given CVD risk, need thorough evaluation for
  vascular disease.

Barbour et al. Semin Nephrol 2001 21 (1) 66-78.
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CVD and CKD

• Primary cause of death is accelerated CVD
• AHA ESRD should be considered highest risk.1
  Considered a CV risk equivalent.
• Entire spectrum of CKD associated with increased
  risk. 2-4
• Very high prevalence of traditional CKD risks.
• HTN cholesterol have U-shaped relationship.

1. Sarnak et al. Circulation  2003  108
2154-2169. 2. Collins et al. Kidney Int
suppl  2003. S24-S31. 3. Henry et al. Kidney
Int  2002 621402-1407. 4. Muntner et al.  J Am
Soc Nephrol  2002 13745-753
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Dyslipidemia

• Lipids combine with apolipoproteins to form
  lipoproteins.
• Lipoprotein profiles are affected by CKD
• HDL, LDL and total cholesterol decline with
  worsening renal function.1
• Dense LDL and lipoprotein (a) are increased. 2
• Elevated lipoprotein(a) is an independent risk
  factor for CVD in hemodialysis patients and is
  associated with vascular events. 3

1. Kanske BL. Am. J Kidney Dis, 1988 32 (suppl 3)
   S142-56.
2. Kwan et al. J. Am. Soc Nephrol 2007 18 (4)
   1246-61.
3. Cressman et al. Circulation 1992 86 (2)
   475-82.

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CV Mortality
Foley et al. Am J Kidney Dis 32
(suppl)S112S115, 1998 Brenner and Rector's The
Kidney, 8th ed.
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CVD in patients with or without CKD, 2009 fig 4.1
(Vol 1)
December 31 point prevalent Medicare enrollees
age 66 older, with fee-for-service coverage for
all of 2009.
U.S. Renal Data System, USRDS 2011 Annual Data
Report, NIH, NIDDK, 2011
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Effects of CKD on Cardiovascular System
McCullough PA Why is chronic kidney disease the
spoiler for cardiovascular outcomes? J Am Coll
Cardiol 41725, 2003
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Non-Traditional CVD Risk Factors in Renal Disease

• Albuminuria
• Malnutrition
• Hyperhomocysteinemia
• Elevated Lp(a)
• Low GFR
• Anemia
• Inflammation
• ECF overload

• Endothelial dysfunction
• Metabolic syndrome
• Abnormal Ca/PO4 metabolism
• Hyperparathyroidism

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Dyslipidemia (cont.)

• Triglycerides tend to increase with CKD,
  especially NS and those on dialysis.1
• NFK recommends lifestyle modifications for those
  with CKD.
• Target LDLC is lt 100 mg/dl for all renal
  patients.

1. Kwan et al. J. Am. Soc Nephrol 2007 18 (4)
1246-61.
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Dyspnea in ESRD

• Pulmonary edema, often non-cardiogenic.
• Failure to decrease est dry weight (EDW) in those
  losing weight.
• Excess intake, exceeding capacity for UF.
• Peritoneal dialysate leakage.
• High output cardiac failure can develop from AV
  grafts or fistulae which can have blood flow of
  gt20-30 of cardiac output .
• Pneumothorax or hemothorax after catheter
  placement.
• Pericardial effusion or cardiac tamponade.

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Initial Rx of Pulmonary Edema in Renal Failure

• Supplemental oxygen.
• Morphine.
• High dose loop Diuretic (if significant residual
  UO).
• May work as vasodilator.
• Preload reduction with nitrates.
• Rx of HTN.
• Definitive rx is fluid salt removal with
  dialysis- not always urgent.

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Chest Pain in CKD

• 50 of renal deaths are related to ischemic
  heart disease, so ACS has to be in Ddx.
• Baseline EKG often abnormal d/t LVH, e-lyte
  disturbances or fluid overload.
• ST segment elevation is indicative of ACS.1
• Chronic troponin elevations are misleading.
• Uremic Pericarditis
• Pulmonary embolus, 12.5 incidence in ESRD vs
  22 in general population.2

1. Goldsmith et al, Kidney Int 2001 60 2059-78.
2. Wiesholder et al, Am J Kidney Dis 1999 33702-8.

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Chest Pain in Renal Disease (cont)

• Higher prevalence of silent ischemia.
• Patient with CKD presenting with chest
  discomfort has 40 cardiac event rate _at_ 30
  days.1
• ESRD patients have highest mortality after AMI. 2

1. McCullough et al  Arch Intern Med 
    2002 1622464.
2. Braumwald

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Approach to ESRD patient with Suspicion of CAD
McCullough PA Kidney Int Suppl 95s51-58, 2005
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Long-term survival by CAD management strategy in
patients with CKD or ESRD.

Keely et al. Am J Cardiol 92509-514, 2003
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Management of CVD in Renal Failure

• Lifestyle modification, as per general
  population.
• Including physical activity when possible.
• Control BP.
• Goal LDL lt 100. JNC7 recognizes CKD as
  independent risk factor
• Have low threshold to evaluate atypical findings
• Worsening fatigue.
• Hypotension in someone with hx HTN.
• Atypical chest discomfort.
• Dyspnea not related to pulmonary edema.

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Calcification vasculature

• Calcifications of the pelvic arteries.
• London GM, et al. Arterial media calcification in
  end-stage renal disease impact on all-cause and
  cardiovascular mortality. Nephrol Dial
  Transplant. 200318(9)1731-1740, by permission
  of Oxford University Press .

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Infections and Renal Disease

• Renal failure immunocompromised state.
• Hypothermia common in renal failure.
• Fever often absent.
• Low grade temps can indicate serious infection.
• Catheters and grafts are often source.
• Higher incidence of HCV.
• Note many antibiotics are dialyzable and require
  dose adjustment .

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Fatal Bacterial Infections in HD PDin
Australia and New Zealand 1995-2005
Johnson et al. AM J Kidney Dis 53290-297.
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Acquired Renal Cystic Disease (ARCD)

• Renal neoplasms seen in 10 of chronic HD
  patients. Adenomas most common.
• With ARCD, prevalent incidence is 20-25.
• Present silently or w flank pain and hematuria.
• RCC has 3-7X higher incidence in ESRD than
  general population.
• ARCD may regress post-tx.

Wein Campbell-Walsh Urology, 9th ed.
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Acquired Renal Cystic Disease (ARCD)
Wein Campbell-Walsh Urology, 9th ed.
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Secondary Hyper-parathyroidism (SPTH)

• CKD is the most common cause of SPTH.
• Failing kidneys do not convert enough vitD to its
  active form.
• Failing kidneys inadequately excrete phosphorus.
  This results in (insoluble) ca-phos complexes
  that remove calcium from the circulation.
• Both processes leads to hypocalcemia secondary
  hyperparathyroidism.
• Vascular calcification common.

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Rx Secondary Hyperparathyroidism

• Low phos diet and phos binders.
• Active Vit D supplements calcitriol (Rocaltrol),
  doxercalciferol (Hectorol), paricalcitol
  (Zemplar)
• Calcimimetic- cinacalcet (Sensipar) mimics the
  action of calcium on tissues by allosteric
  activation of ca-sensing receptor.
• Educate and reinforce, re-educate.

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Summary

• Renal failure is a systemic disease that affects
  every other organ system.
• For any age, CKD and ESRD patients have markedly
  increased mortality compared to general
  population.
• CVD has very high incidence and needs to be
  looked for and treated aggressively.
• Vague presentations of infection or CVD are
  common.

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Questions?

• cstaffeld_at_ochsner.org