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CKD for the PCP: Staging, Progression, Complications - Part 1

Manish Suneja, MD and Neda Frayha, MD
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Chronic kidney disease can feel overwhelming and is often managed in primary care, especially in the early stages. In this conversation, Neda discusses what the PCP needs to know about CKD with expert nephrologist, Dr. Manish Suneja.

Pearls:

  • Recognizing CKD early is important →  60 < GFR < 90 with proteinuria/hematuria/abnormal ultrasound OR GFR < 60 is diagnostic.

  • To prevent kidney disease progression treat the underlying causes (hypertension and diabetes), encourage smoking cessation, avoid nephrotoxic medications and consider use of RAAS inhibitors like ACEs and ARBs.

  • You can treat complications of CKD that include anemia, bone and mineral disorders but remember that the evidence of benefit for treating bone disorders in particular is weak.

 

  • Stages of CKD:

    • Stage 1: GFR > 120 + finding of kidney disease (ie: hematuria, proteinuria or abnormal kidney ultrasound) → classic example is a patient with early diabetes who has hyperfiltration (GFR > 120) + proteinuria

    • Stage 2: GFR 60-90 + finding of kidney disease (ie: hematuria, proteinuria or abnormal kidney ultrasound)

    • Stage 3: GFR 30-59 at this point you don’t have to have another finding of kidney disease

    • Stage 4: GFR 15-29

    • Stage 5: GFR < 15 → may be divided into on dialysis vs. not on dialysis

  • Slowing the progression of CKD:

    • The first step is recognizing the stages. Stages 1 and 2 are important to recognize to slow the progression

    • Most common causes: diabetes and hypertension

    • RAAS inhibition

      • If hypertension, provide RAAS inhibition through an ACE or ARB

      • Pearl:

        • If Cr doesn’t increase more than 30%, most likely it is a hemodynamic effect. Don’t discontinue the medication.

        • If K increases from 4.7 to 5.2, think about underlying causes but don’t discontinue the medication. Manage it with a loop diuretic if they also have hypertension or suggest dietary changes.

    • SGLT2 inhibition

      • If diabetes, consider SGLT2 inhibitors, especially if you have diabetic nephropathy

      • Mounting evidence that it may be additive to RAAS inhibition and for those people who don’t have diabetes

    • Metabolic acidosis

      • Treating metabolic acidosis may help slow progression

    • Treat risk factors:

      • Smoking cessation

      • Cardiovascular comorbidities

    • Blood pressure target

      • There is not consensus on what is the best number

      • Minimum would be 140/90 but may be even as low as 120/80 based on the most recent data

      • Fall risk may to be overemphasized but treatment needs to be tailored to each individual patient

  • Manage the complications of CKD:

    • 1. Anemia WITH iron deficiency

      • Starts at around Stage 3B (GFR 30-45) and more prominent at Stage 4

      • Pearl: Target Hb should be 10-11 NOT 12-13

        • TREAT trial in 2009 showed treating to Hb 12-13 led to increased strokes

        • If they have fatigue or other symptoms then you may need to consider EPO to get the them to that target 10-11

      • Check iron studies regularly knowing that you’ll have both anemia of chronic disease as well as iron deficiency anemia from poor iron absorption

      • Consider IV iron repletion

      • Pearl: Don’t prescribe erythropoietin without repleting iron stores

    • 2. Bone and mineral disorders (PTH, phosphorus, vitamin D)

      • Evidence for treating these disorders (and the numbers) is very weak

        • Pearl: If the pill burden is high for patients, this may be an area to compromise since the data for benefit here is weak

      • Check a 25-hydroxy vitamin D level and replete if < 20. Once repleted you can then use calcitriol (active vitamin D form made in the kidney that becomes deficient)

      • Check phosphorus level if elevated (usually at Stage 4) → if elevated choose a binding agent to use with meals so that the binders actually bind the phosphorus in your stools and get excreted

 

References:

  1. Webster AC, Nagler EV, et al. Chronic Kidney Disease. Lancet. 2017; 389(10075):1238-1252. doi: 10.1016/S0140-6736(16)32064-5. Epub 2016 Nov 23. PMID: 27887750.

  2. Chen TK, Knicely DH, Grams ME. Chronic Kidney Disease Diagnosis and Management: A Review. JAMA. 2019;322(13):1294-1304. PMID: 31573641

  3. Buelt, A. Chronic Kidney Disease: Evaluation and Treatment Guidelines from the VA/DoD. Am Fam Physician. 2020 Sep 15;102(6):378-379. Link

  4. Heerspink HJL, Stefánsson BV, et al; DAPA-CKD Trial Committees and Investigators. Dapagliflozin in patients with chronic kidney disease. N Engl J Med. 2020; 383(15):1436-1446. Epub 2020 Sep 24. PMID: 32970396.

  5. Chen TK, Knicely DH, Grams ME. Chronic kidney disease diagnosis and management: A review. JAMA. 2019; 322(13):1294–1304. PMID: 31573641.

  6. Pfeffer MA, Burdmann EA, et al; TREAT Investigators. A trial of darbepoetin alfa in type 2 diabetes and chronic kidney disease. N Engl J Med. 2009; 361(21):2019-32. Epub 2009 Oct 30. PMID: 19880844.

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