Thursday, March 22, 2018

#NephMadness Living Kidney Donor Case Challenge #LKDCC #4

Please note these are fictional cases with open access stock images. They do not represent real cases.

Read more about the #NephMadness Transplantation Region at the AJKD Blog and submit your #NephMadness brackets here by Friday March 30!

Created by Kate Robson (Nephrologist, Melbourne, Australia and NSMC Intern 2018)

Wednesday, March 21, 2018

#NephMadness Living Kidney Donor Case Challenge #LKDCC #3

Barry, 62, is under evaluation as a kidney donor to his wife Susan.
At his first appointment, you measure his blood pressure at 155/95.
Which one of the following is correct?
A) You should tell Barry that he is ineligible for donation given that he his hypertensive.
B) A single office BP reading is insufficient to make a decision about eligibility.
C) If Barry needs antihypertensive medication, he cannot be a kidney donor.
D) You should counsel Barry that studies show his BP will increase significantly after kidney donation.

Here's how you responded:

Answer: B.

The impact of kidney donation on blood pressure is not clearly defined. Studies in this area have been limited by small numbers, heterogeneous parameters, and absence of suitable control groups.

While there are several earlier studies without a comparator group, more recent research comparing blood pressure in donors with a matched control group provide more useful information. Ibrahim et al compared 255 donors from their larger Minnesota cohort with a matched control group, and found no statistically significant difference in the proportion of those with blood pressure of 140/90 or higher (14.4% donors vs 18.7% controls). A 2006 meta-analysis examined pooled data for a total of 5145 donors from 9 controlled studies (comparing donors with healthy adults matched for age, sex and ethnicity). A small increase in blood pressure (6mmHg systolic and 4mmHg diastolic) was noted in donors over 10-year follow-up. Finally, a 2015 prospective study of 182 living donors and 171 matched controls found a (very!) small increase in blood pressure (2/1mmHg) after 3 years, with no significant difference between the two groups.

Our knowledge of outcomes for donors with pre-donation hypertension is even more limited. Textor et al reported on 148 Caucasian donors, before and up to 12 months after donation. 24 donors had hypertension at baseline (average ambulatory blood pressure greater than 135/85mmHg, or on antihypertensive treatment). These donors were older and had a higher BMI than normotensive donors. They had normal GFR and no proteinuria, and were treated with both pharmacological and non-pharmacological methods to control blood pressure. There was no significant increase in blood pressures (indeed, a slight decrease), in this very short follow-up period.

There is no clear evidence that kidney donation increases the risk of hypertension in most donors. Higher blood pressure, BMI and age do, however, confer greater risk in potential donors, as in the general population. As recommended by KDIGO Guidelines, pre-donation assessment should involve at least 2 office measurements of blood pressure and, where there’s uncertainty/variability, ambulatory blood pressure monitoring. Where blood pressure can be controlled with 1 or 2 agents, and there is no end-organ damage, hypertension alone is not considered a contraindication to donation. Pre-donation, individualized risk assessment, careful counselling and optimisation of risk factors is essential. Afterwards, close follow-up for management of hypertension and secondary prevention strategies for cardiovascular disease is key.

Don't agree with the answer? Get on twitter and tell us what you think...
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Complete the 7-day challenge and you'll have a whole new perspective on Living Kidney Donor Risk and the #NephMadness #TransplantRegion
Don't forget to submit your #NephMadness brackets here

Please note these are fictional cases with open access stock images. They do not represent real cases.
Created by Kate Robson (Nephrologist, Melbourne, Australia and NSMC Intern 2018)

Tuesday, March 20, 2018

#NephMadness Living Kidney Donor Case Challenge #LKDCC #2

Hayley, 30, wishes to donate a kidney to her husband Rob.  They have a 3 year-old child. Hayley has no known medical problems and is a non-smoker. Her BMI is 23 kg/m2, her blood pressure is 110/70 mmHg and physical examination is unremarkable. The urinalysis shows no haematuria or proteinuria. Her measured eGFR is 104ml/min/1.73m2.
If Hayley and Rob decide to have another child after donation,
A) We should reassure Hayley that her kidney donation will not have any bearing on the subsequent pregnancy.
B) An alternative donor should be sought, because pregnancy after donation is contraindicated.
C) Hayley’s risk of pre-eclampsia and gestational hypertension could be higher than in her first pregnancy.
D) We must counsel Hayley & Rob that there is a higher risk of perinatal death with the subsequent pregnancy.

Here's how you responded:

Correct Answer: C

A 2015 Canadian retrospective cohort study examined 85 female kidney donors, comparing them with 510 healthy non-donors matched for age, income, rurality, and number of previous pregnancies. There were 131 (post-donation) pregnancies in donors, and 788 in the control group. Gestational hypertension and pre-eclampsia were more common in the donor group (11% vs 5%) but there were no differences in rates of preterm birth or low birth weight, and no maternal or perinatal deaths. The study is limited by the lack of detailed information contributing to the diagnoses, such as blood pressures, GFR and urinalysis. It is possible that a coded diagnosis of pre-eclampsia was more likely to be made in a donor, due to more intensive surveillance or baseline proteinuria.

A Norwegian study of 326 female donors compared pregnancies before and after donation. Gestational hypertension or pre-eclampsia complicated 8% of pregnancies after donation, compared with 2.6% of pre-donation pregnancies.
There was an additional comparison between donor and non-donor pregnancies from a national birth registry, although baseline prognostic factors differed significantly between these groups, including a difference in average maternal age of 5 years.

Also comparing pregnancies before and after donation, a single-centre study in Minnesota collected self-reported data from 1085 women. While post-donation pregnancy outcomes were similar to those reported in the general population USA-wide, they were inferior to pre-donation outcomes (e.g. pre-eclampsia: 5.5% vs 0.8%). The study was based on patient recall alone, and saw a loss to follow-up of almost 40%. We should also consider that women with a history of gestational hypertension or pre-eclampsia may be less likely to become kidney donors, potentially resulting in an exaggerated difference between pre-donation and post-donation pregnancy outcomes in both this and the Norwegian study.

The available evidence suggests that kidney donation does not increase the risk of pregnancy complications above that of the general population. There may be an increase in risk of gestational hypertension and pre-eclampsia compared with pre-donation rates, but this has not been shown to result in higher rates of maternal or fetal death.

To help this family make the best decision for them, we should counsel Hayley and Rob about the available information, and put this into context for Hayley’s individual situation. Hayley and Rob’s family planning is not itself a contraindication to donation.

Don't agree with the answer? Get on twitter and tell us what you think...
Submit your responses for Case 3 now!
Complete the 7-day challenge and you'll have a whole new perspective on Living Kidney Donor Risk and the #NephMadness #TransplantRegion
Don't forget to submit your #NephMadness brackets here

These are fictional cases with open access stock images and do not represent real cases.

Created by Kate Robson (Nephrologist, Melbourne, Australia & NSMC Intern 2018)

Monday, March 19, 2018

A New Breed of Nephrologists: Can We Change the Practice Paradigm?

I want you to put yourself in the shoes of your average nephrologist, it seems frenetic when looked at from a birds eye view. A typical day begins with rounding on first shift dialysis patients, then on to seeing hospital patients at a different location. After tucking in patients who need urgent care, the next stop is clinic, yet again at a different location. Clinic time is peppered with phone calls with follow-up questions after morning rounds diverting attention from the clinic patients there to seek advice in front of you. We’re not factoring in the possibility of urgent consults (i.e.emergent dialysis or severe hyponatremia) or coverage at Long Term Acute Care Facilities (LTAC’s) yet. Add to this the additional time needed to round on the evening dialysis patients or going to see that late urgent consult, it all seems draining. Underestimated in this picture is that of lag time, the distance between the dialysis unit, the hospital or the clinic; depending on where one works this can be upwards of one to two hours of pure driving/lag time. Those two hours could have been spent seeing patients or focusing on the ones already on the roster! The icing on the cake is night coverage - the uncertainty of a restful sleep after a hectic day with the potential to be called into the hospital in the middle of the night. Could this be a reason why residents are not considering nephrology? They see the clinical nephrologist stretched thin and starting to show signs of burnout?.

It’s no secret that interest in nephrology has waned and much interest has been paid to hone in on the exact reasons for this observed trend. On the one hand, it’s sad to see a field I love need some resuscitation yet on the other, there’s a bold charge from angles such as academia and physician engagement which is comforting and refreshing to see. These visionaries are making nephrology cool again;nerdy is the new cool. The topic I’m going to talk about is based on my experiences thus far and reflective of a personal journey. I’ve recently had the privilege of joining the Nephrology Social Media Collective as well as joining a private practice nephrology group, Dallas Renal Group (DRG). These new opportunities have allowed me to rub elbows with some of the smartest clinicians and innovators in the field who have found a knack for weaving nephrology with fun ways of learning and teaching others how to run a successful practice. One aspect that may be a contributing factor to the current trends is that of the structure of what a real life nephrology practice looks like. En route to becoming a nephrologist, a pit stop was as a hospitalist, what can I say, the siren song of the nephrons was too strong. Having that experience coupled with seeing a pioneering prototype of a novel practice structure at DRG has given me perspective that can be applied broadly and hopefully attract future nephrologists.

What’s being done? Locally at the fellowship level, faculty and training program directors have increased efforts to innovate and increase interest among residents via innovative teaching techniques and creative nephrology  electives for medicine residents. At the national level, ASN started the Kidney Treks program to enhance interest in medical students and residents. In addition, outside the confines of institutions, there is a blossoming charge being led by visionaries in the academic arena embracing use of social media platforms such as Twitter to conduct journal clubs with the hashtag #NephJC, and the Nephrology Social Media Collective #NSMC which aims to connect, mentor, and inspire future nephrologists from around the world. In the coming month we’ll be looking forward to NephMadness, a play on March Madness using a game format and competitive enthusiasts to get the community engaged with current topics in nephrology moderated by world renowned experts and KIDNEYcon, a conference with a focus on hands on workshops. In the business/leadership realm there is Nephrology Business Leadership University (NBLU), an initiative created by physician leaders at DRG and UCSD that’s now expanded to include other practices as well. This course is teaching graduating fellows the economics and business of a nephrology practice, some of the intangibles acquired often after years of private practice. Topics covered at NBLU include transitioning from fellowship to private practice, leadership tracks, billing and coding, understanding insurance and reimbursement and marketing strategies topics that are not often addressed during fellowship.

There’s already been success in spurring interest in the game, what about switching up how the game looks like in practice? It’s interesting and ironic to note that most fellowship programs have a focused rotation format with months devoted solely to inpatient, transplant, research and dialysis with clinic incorporated throughout begging the question as to why as attendings are we juggling our time. A field where cues can be taken from is hospitalist medicine. The lure of hospitalist medicine is shift work, work life balance and a decent compensation. Hospitalist medicine has impressively boomed since its advent in 1995 tallying a total of 50,000 physicians in 2016, roughly half of internists. Why can’t nephrology follow a similar pattern? Nephrologists need to entertain morphing their current practice structures to decrease “windshield time” which will translate to increased efficiency, better patient outcomes, and decreased physician burnout. Finding a new system that works will definitely take some time but also innovation.

There are novel options such as nephro-hospitalist and nephro-nocturnist. These two positions are reminiscent of internal medicine training and current hospitalist structures where there are focused rotations for 4-6 weeks at a time, including night float, divvied up amongst all the residents. In a group practice with as many attendings as a traditional residency program, these ideas potentially are feasible. Having worked as a hospitalist in the past, one of the most attractive aspects was the schedule allowing me the ability to travel for medical relief work abroad primarily with the Syrian American Medical Society and the Islamic Medical Association of North America while not sacrificing compensation.

As fate would have it, the unique role of the nephro-hospitalist has been piloted with success at my current job at DRG. From a logistical perspective, there have to be enough inpatients requiring nephrology consultation to justify the existence of a nephro-hospitalist. DRG happens to be a large and growing nephrology group in the Dallas, Texas area with a robust patient population and thus was ideally suited for this new structure. However, there are pros and cons to consider. Pros being a flexible schedule, since you’re aware of the census and it’s acuity, you can tailor when you’re going to round. You’re delivering efficient care knowing that there is no second or third site to rush to throughout the day, minimizing lag/windshield time. You know that your responsibility is limited to the confines of the hospital. The position of a nephro-hospitalist is mutually beneficial for the hospital and a powerful asset given the assurance of knowing that a sick patient will be seen quickly when a nephrologist is onsite. To complement the nephro-hospitalist, there would be a nephrologist focusing solely on the outpatient realm (clinic and dialysis). This would allow for focused attention to patients in the clinic and the dialysis unit with less distraction from hospital phone calls. For a nephrologist, efficiency and decreased lag time is the name of the game.

The caveat of focusing on hospital patients is that invariably there is a higher level of acuity which may predispose the physician in this role to burnout. Going forward the development of hard patient caps, established backup systems for when the census becomes overwhelming or perhaps more time off may need to be considered. Some potential downsides of this model is that both the nephro-hospitalist and outpatient nephrologist could lose their respective skills of the other setting. This notion can be countered with the fact that in this layout every group member is taking calls on the weekends hence staying in touch with inpatient nephrology. A blended rotation approach has also been implemented at DRG maintaining the best of both worlds. Similar to a rotation schedule but on a smaller scale. Each physician, out of a group of four, rotates through the hospital for a week at a time, coinciding with and preceding their weekend on call. Benefits of this layout are the ability to stay in touch with outpatient nephrology, focused care, plus the added perk of knowing all the patients for the weekend call making rounding much more fluid.

Another idea is the nephrology nocturnist. This is aimed aimed at handling urgent consults and phone calls at night. The sole task would be to address emergent issues and see consults overnight. Theoretically this would certainly lead to a better quality of life for the daytime physicians who at present are conducting full days of work despite being summoned in the middle of the night for emergent consults. Sleep is known to be an important contributor to well-being. In fact, poor hygiene is associated with cognitive decline. Having a nephrologist on standby could lead to better physician wellness and potentially higher satisfaction from patients and referral sources. In the hospitalist world finding and retaining nocturnists is difficult, which is not surprising. Despite this challenge, nocturnists contribute to the success of several hospitalist programs. There may be some feasibility in piloting a nocturnist rotation in fellowship programs or private practice. As an example, nocturnal nephrology coverage is currently in place at Icahn Mount Sinai Nephrology fellowship program as well as SUNY Downstate. Thus, this is not a completely foreign concept in nephrology.

The two potential alternative staffing models listed above are assuming that the amount of patients needed to generate revenue for the practice remain constant. Physicians find themselves guided through structured paths in the process of obtaining an undergraduate degree to graduating from a residency and/or fellowship. These are predetermined paths and frankly little attention is paid to the economics of medicine throughout. Once doctors reach the workforce however, that lack of exposure to business and finance is apparent once decisions are made regarding how best to optimize valuable time. At NBLU there is a heavy emphasis on the concept of shifting focus away from factors not immediately in our control, like reimbursements and regulations. Instead, more focus should be placed on leadership roles as well as exploring passive revenue models. Leadership roles endow a sense of empowerment among those in them and ensure our voice and point of view as physicians are heard. Passive revenue models can help us work “smarter” instead of “harder.” Some options include investing in dialysis units, research, access centers and real estate.

These new models and ideas can help increase job satisfaction and decrease the burnout among nephrologists. In addition, fellows in programs with such models might have better coverage systems and experience more “learner” centered fellowships rather than “service” centered ones. It is refreshing to see these new trends emerging from academics and private practices who are leading the way in taking on the challenges presented and joining other nephrologists in reinvigorating the field. Time will only tell how successful these models are, judging from the success of the hospitalist mold and pilot structural changes at DRG, hopefully these will be as well.
Nimra Sarfaraz
Dallas Renal Group

Dallas Texas
NSMC Intern, Class of 2018

Disclosures/Conflict of Interest:
I am currently an employee of Dallas Renal Group. I am on the oversight committee for Nephrology Business Leadership University. I am currently an intern with the Nephrology Social Media Collective.

#NephMadness Living Kidney Donor Case Challenge #LKDCC #1

Rajiv, 39, wants to donate a kidney to his sister-in-law, Shen. His brother, Shen’s husband, is healthy, but unfortunately not a good match for Shen. Rajiv has no past medical history, is a non-smoker and his BMI is 24. His BP is measured at 120/75. Physical examination and urinalysis are unremarkable. Rajiv’s wife is particularly concerned about the future risks to Rajiv.

Which of the following would you advise?
A) After donation, Rajiv has a higher risk of developing ESKD than the general population.
B) After donation, Rajiv may be more likely to develop ESKD than his healthy 37 year-old brother.
C) Annual urinalysis & BP monitoring is recommended only for the first five years after donation.
D) Rajiv’s wife’s concerns are not relevant to the decision-making process.

Here's how you responded:

Correct Answer: B
For many years, potential kidney donors responding to the call to ‘Share your Spare’ were counselled that donation did not increase their risk of kidney failure. This advice was based on data showing that the rate of ESKD among kidney donors was equal or indeed lower than in age-matched controls (see e.g. these studies from 1997 and 2009). But, owing to stringent pre-donation assessment, as well as follow-up care afterwards, donors are usually particularly healthy compared with the rest of the population. It makes more sense, therefore, for studies to compare donors with matched healthy controls.  That was the approach taken by two more recent studies.

In the first, Mjoen et al compared 1901 Norwegian donors with a control group of 32,621 people who would have been deemed fit for donation. Median follow-up time was 15.1 (range 1.5-43.9) and 24.9 (range 0.1-26) years respectively. ESKD ensued in 9 (0.47%) donors and 22 (0.07%) controls, which corresponds to a hazard ratio for donors of 11.38, but a very small absolute increase in risk (i.e. 11 times almost zero). There are several methodological issues to consider, too. The mean age at baseline was significantly higher in donors than in non-donors (46 vs 37.6 years). The longer maximum follow-up for donors may also have led to a higher detection rate of ESKD. Furthermore, 80% of donors were first-degree relatives of the recipient, (unrelated donors were first accepted in Norway in 1983), and 7/9 donors who developed ESKD had a primary renal disease, suggesting genetic factors may be important.

Shortly after, Muzaale et al reported the long-term outcomes of 96,217 donors in the USA, with a control group from the NHANES III study matched for age, sex, race, education, BMI, smoking status and blood pressure. Median follow-up was 7.6 years for donors and 15 years for non-donors. ESKD was seen in 99 (0.1%) donors, compared with 36 (0.04%) non-donors (p<0.001). Estimated lifetime risk of ESKD was 90 per 10,000 in donors, compared with 14 per 10,000 in matched healthy non-donors and 326 per 100,000 in the general population. In subgroup analysis, a higher cumulative incidence of ESKD was noted in African-American donors and in donors aged over 60 years at the time of donation.

These two studies suggest that, when compared with a matched healthy population, donors have a higher relative risk of ESKD in the long term. This information should be part of the consent process for potential donors, particularly for those with additional risk factors. Nonetheless, the absolute risk remains very low, and substantially lower than in the general population.

Of course, when counselling an individual about their long-term post-donation risk of ESKD, it's important to think about their baseline (pre-donation) risk: this risk tool can help you see how different factors impact an individual's baseline (pre-donation) risk of ESKD.

Long-term annual follow-up is widely recommended for living kidney donors  (see e.g. KDIGO Guidelines and UK BTS Guidelines), and should address not only renal function, but cardiovascular risk factors, lifestyle factors and psychosocial well-being. This responsibility is particularly important in considering overseas donors.

Finally, thinking about Rajiv’s wife’s concerns, psychosocial support is essential for successful kidney donation. A multi-national qualitative study found that in the very small proportion of donors who reported a negative impact on quality of life after donation, family discord and lack of support were key risk factors.

Don't agree with the answer? Get on twitter and share your thoughts...
Submit your responses for Case 2 now!
Complete the 7-day challenge and you'll have a whole new perspective on Living Kidney Donor Risk and the #NephMadness #TransplantRegion
Don't forget to submit your #NephMadness brackets here

Please note these are fictional cases with open access stock images. They do not represent real cases.

Created by Kate Robson (Nephrologist, Melbourne, Australia and NSMC Intern 2018)

Sunday, March 18, 2018

Chronic Kidney Disease for the Medical Resident: A Cheat Sheet for Primary Care Providers

1 in 6 patient one-liners have Chronic kidney disease (CKD) mixed with a list of comorbidities. It’s easy for a primary care provider (PCP) to forget about the kidneys until it’s too late, or simply pass off the management to a more-than-willing Nephrologist. But knowing the basics of CKD can go a long way for PCPs and some of the new literature can help guide treatment decisions even before getting an office appointment with official bean lovers. As part of the Nephrology Social Media Collective (NSMC) internship I was tasked with writing my first blog post. I decided to tackle a subject bridging my interest with primary care with nephrology.  This is a quick rundown of everything a PCP should know about protecting the most important organ.

CKD is defined as:
1)   The presence of markers of kidney damage for greater than 3 months in blood, urine, or on imaging
a)    e.g proteinuria, non-urological hematuria, polycystic kidney disease, horseshoe kidney, etc.
2)   The presence of a GFR of less than 60 mL/min/1.73 m2 for more than 3 months

Risk Factors
The most common cause of end-stage kidney (ESKD) disease is diabetes (44%), followed by hypertension (29%). The cause is usually from an increase in intraglomerular pressure which is damaging to the glomerular  filtering capabilities. Other risk factors include a family history of CKD, autoimmune disease (e.g. SLE, vasculitis, scleroderma), HIV, Hepatitis B or C, amyloidosis, obstructive nephropathy from recurrent UTI or nephrolithiasis,  and certain medications (analgesics, immune suppressants, HIV medications). Acute kidney injuries may also contribute to CKD, particularly if requiring inpatient dialysis. Recent evidence suggests pediatric kidney disease may also be associated with adult ESKD.

Staging and Estimating GFR
Staging CKD is most frequently done by calculating the estimated glomerular function rate (eGFR) as a proxy for kidney function. These calculations are often based on a patient’s serum creatinine (a muscle metabolite that is filtered in the kidney). Of the three most common calculators (CKD-EPI, MDRD, Cockroft-Gault equation), the CKD-EPI is the most accurate at predicting mortality and ESKD and generally is what is recommended for use. (of note- many dose adjustment for drugs still use Cockroft-Gault- look carefully at this when looking at dose adjustments).

Link to CKD-EPI calculator found here:

After calculating the eGFR, CKD can be staged into 1 of 5 stages. Using the GFR clock is one way to remember the eGFR cut-offs for each CKD stage.

Because the above calculators rely on creatinine (which can vary in patients with extreme muscle mass e.g. sarcopenic patients such as the frail elderly or sarco-full patients such as body-builders), creatinine clearance can also be estimated and used to stage CKD.  24-hour urine creatinine clearance equation works for all patients regardless of size. Creatinine clearance is based on the ratio of urine creatinine and plasma creatinine.

CrCl = Urine Cr (mg/dl) * Urine volume (ml)] / [Plasma Cr (mg/dl) * Time (min)

Cystatin C is another biomarker that can be used for estimated eGFR. Like creatinine clearance, it is mostly useful in patients where creatinine is a bad estimate, though may also help provide more accurate kidney function estimates when combined with above calculations.

CKD Staging is also based on the level of proteinuria seen in the patient. If there is proteinuria or greater than 300mg albumin/mg/g Cr in a urine protein:creatinine ratio, then the proteinuria is staged as A3. If between 30-300 (microalbuminuria), the staging is A2. A1 is if there is no significant proteinuria or microalbuminuria.

The eGFR and proteinuria offers a general prognosis as demonstrated in the Heat Map.

With an estimated GFR and knowledge of proteinuria, the risk of kidney failure requiring dialysis or transplant can be calculated using a Kidney Failure Risk calculator based on Tangri et al, JAMA 2016. More generally, a lower eGFR has an observed association with the risk of death, cardiovascular events, and hospitalization.

Initial Work-up
Recommended workup for new diagnosis of CKD:
      Serum electrolytes for eGFR and electrolyte abnormalities (e.g. metabolic acidosis)
      Complete Blood Cell Count (Anemia)
      Lipid profile
      Uric Acid
      Serum albumin
      Renal ultrasound
      to look for hydronephrosis, obstruction, cysts, stones, and assess kidney size and characterization
      Quantify proteinuria with urine protein-to-creatinine ratio (Urine albumin-to-creatinine will miss multiple myeloma Bence-Jones proteins)
      Look for hematuria or other signs of glomerulonephritis
      Consider biopsy if significant proteinuria and no history of diabetes

In patients with CKD G3 (eGFR less than 60 mL.min):
      Serum calcium, phosphorus, PTH, Vitamin D to assess for Bone Mineral Disease

If suggested by the history and physical examination and UA:
      Antinuclear antibody testing to evaluate for lupus
      Hepatitis B and C, and HIV serology
      Serum antineutrophil cytoplasmic antibodies to evaluate for ANCA-associated vasculitis
      Serum and urine protein immunoelectrophoresis to test for multiple myeloma

All patients with at least CKD G4 disease (GFR ≤30 mL/min/1.73 m2 ) should establish care with a nephrologist. Consultation is also recommended if proteinuria greater than 3g / 24 hr, evidence of glomerulonephritis (hematuria, proteinuria, and hypertension), an eGFR decline of 50% within 1 year.

General management should also prioritize treatment of the underlying condition (e.g. hypertension and diabetes) to reverse the progression of CKD.

ACE-inhibitors demonstrate a significant reduction in progression of CKD and reduction in proteinuria per the RENAAL, IDNT, and other trials. Fewer patients had progression to ESKD though a mortality benefit was not observed.

Of note, ACE-inhibitors or ARBs (RAAS blockade) are likely to cause a benign increase in serum creatinine. In general, if the creatinine bump greater than 30%, RAAS blockade should be discontinued. An increase in creatinine after ACE-I may show greatest risk of mortality (though it is unclear what would happen if the patients with bumps were not on ACE-I, so this is not an indication to necessarily discontinue therapy).

Blood Pressure Treatment
Per KDOQI 2012 guidelines, target blood pressure in CKD is less than 130 over 80 mm Hg. With<130 mmhg.="" span="" style="mso-spacerun: yes;"> <130 mmhg.="" nbsp="" span="">ACE-inhibitors being the first line drug.

Diabetes Control
Metformin: if eGFR 30-45 and already on metformin (and this is not AKI) can continue metformin. Do not start NEW if eGFR is 30-45, but ok if higher than 45.  

SGLT2 inhibitors (i.e. Empagliflozin and Canagliflozin) are associated with lower rates of worsening nephropathy, progression to macroalbuminuria, initiation of renal replacement therapy and mortality. (EMPA-Reg, EMPA-Reg ESRD + CANVAS). However, studies demonstrating their effectiveness in CKD are ongoing.

Bone Mineral Disease Screening
All patients with CKD G4 should be screened for secondary and tertiary hyperparathyroidism. The screening labs are a PTH, phosphorus, calcium and vitamin D level. Further information can be found at the KDIGO guidelines on BMD.

Depression Screening
Depression in CKD patients affects approximately 20% of all CKD patients.

There are multiple causes of anemia in patients with CKD including iron deficiency. KDIGO recommends intravenous iron for anemic, nondialysis, CKD patients with transferrin saturation
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Guidelines remain controversial but a full discussion can be found at the AKJD Blog or in the recent NEJM Review.

Medications to Avoid
Use of Bactrim (trimethoprim-sulfamethoxazole) was associated with 3 excess cardiac deaths per 1,000 prescriptions presumably due to hyperkalemia (e.g.  patients with CKD are higher risk)

Baclofen- should be avoided in ESKD or eGFR less than 30 and dose reduced with eGFR between 30-6o.<30 .="" 30-60="" adjustment.="" dose="" font="" requires="">

Proton Pump Inhibtors
Observational data demonstrates a link between proton pump inhibitors and CKD.

Renally dosed medications
Certain medications, such as gabapentin, also will require renal adjustment for dosing.

Contrast-induced kidney injury (CIN) may be overestimated in literature. The AMACING trial shows that pre-hydration does not reduce kidney injury in those exposed to contrast.

Patients with CKD depend on prostaglandins for vasodilation of afferent arterioles and renal blood flow. NSAIDs block prostaglandin activity and can cause acute kidney injury.  KDIGO Guidelines recommend avoiding NSAIDS in patients with CKD, but the evidence suggests that risk of NSAID use in CKD patients is pretty low: The Male Physician Study showed no elevation in serum creatinine with consistent NSAID use. However, the PRECISION Trial showed only ~1% risk of kidney events in CKD patients with daily high-dose NSAIDs.

For a more succinct review of the above, check out the new ClinicWiki page on Chronic Kidney Disease.

Post written by
Justin Berk, MD, MPH  @justinberk
Med-Peds Resident, John Hopkins University
NSMC Intern 2018