Tag: CKD

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CKD in the NYT

Kidney Disease a Takes a Growing Toll

Nice article on the increasing prevelance of chronic kidney disease. They even mention the controversy of geriatric CKD, one of my newest interests.

The article mentions the NKF of Michigan’s project to raise awareness of CKD by using hair dressers. I am the newest member of the NKF of Michigan’s Scientific Advisory Board.

Also the article has a quote by Steven Fadem, a nephrologist I shared a limo with last week at the EVOLVE Primary Investigator’s Meeting. Crazy small world.

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KDIGO


bill goodman talking on KDIGO. Goodman wrote the article that interested me in the topic of vascular calcification and binder choice.

What is KDIGO
Kidney Disease Improving Global Outcomes
established in 2003

Independent non-profit, established by the NKF
The concept was to take K/DOQI and generalize the guidelines for a global audience.

The KDIGO mission is to provide:

  • Clinical Practice Guidelines
  • Guideline database
  • Work groups
  • Controversy conferences
  • Mineral and bone inititative (in draft)
  • Hepatitis C in kidney disease (coming)
  • Care of transplant patient (coming)
  • Acute kidney disease (coming)

CKD Mineral and Bone Disease
A rose from the perception that international perspective needed to define renal osteodystrophy

use the phrase ROD exclusively to define: alterations in bone morphology in patients with CKD
classification based on bone histology, bone turnover, mineralization and volume.

CKD-MBD is a systemic disorder of mineral and bone metabolism due to ckd manifested by either one or a combination of the following:

  • abnormalities of Ca, Phos, PTH, Vitamin D
  • abnormal bone turnover, mineralization, volume, linear growth or strength
  • vascular or soft tissue calcification

KDIGO revisited the concept of guidelines
They graded evidence and created their guidelines by limitting the data to:

  • RCT of at least six months in duration
  • N>50 excepts for pediatrics and bone biopsy
  • Intermediate endpoints including: BMD, bone biopsy, vascular calcification and biochemical endpoints are not considered unless they have been validated prospectively [unclear if any surrogates have been validated]
  • Observational studies acceptable if a clinical outcome examined conducted with a high methodological quality and had a relative risk of >2.0 or <0.5

treatment of CKD-MBD

  • lowering high phos
  • abnormal PTH levels in CKD-MBD
  • treatment of bone and bisphosphonates, other osteoporosis medication and growth hormone
  • evaluation and treatment of kidney transplant bone disease

there is little evidence to provide guidance for a specific therapeutic target range for any biochemical parameter

  • extreme values are associated with greater mortality risk
  • little evidence to support preferred treatments

KDIGO concluded that PTH guidelines are mainly opinion based and not informed by randomized clinical trials

150-300 is based on evidence just not rct and outdated

phos and calcium guidelines are loose

repeated emphasis through out document on the lack of evidence from RCT with hard outcomes

Data Gaps

Evolve is really important, largest prospective clinical trial on dialysis population

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Renal Week 2008: CVD and CKD: Case 7

66 yo woman with ESRD due to analgesic nephropathy. Hx of Crohn’s Disease. Extended criteria deceased donor allograft transplant 1.5 yrs ago.

Now SBP of 160.

Next Speaker Ojo. Greatest name in Nephrology.

CVD and CKD in Transplantation

Progressive reduction of acute rejection since 2000 from 17.4 to 10.3% at one year. This should improve outcome of graft and patient; however post-transplant life-span has decreased from 14 in 1995 to 12.7 in ’06.

CVD is the explanation for this conundrum.

After the first year the most common cause of loss of graft is: death with a functioning graft (56%). This is twice as common as number 2, chronic rejection (21%).

43.5% die of CVD.

Hypertension, DM, hypercholesterolemia, obesity, and anemia are all more prevalent in transplant patients than transplant candidates or prevalent dialysis patients.

Focus on immunosupressant drugs

  • In HIV patients with lower cd4 have higher higher CVD death rate
  • Same relationship of CD4 to CVD is seen in patients with radiation exposure (Hiroshima) causing lower cd4 counts
  • also seen in transplant patients.

Rabbit data showing that increased cholesterol plaques with concurrent CSA, without change in lipid profile. Roselaar jci 1995 96 1389.

Steroids are dangerous even at low doses in the normal population.

CSA increase BP.

CSA also causes endothelial dysfunction.

Sirolimus is antiatherogenic, as seen in cardiac stents.
MMF also appears to reduce cholesterol plaque Romero Atherosclerosis 2000: 152:127-133.

Cr alone is a predictor of CVD independent of immunosupression and traditional risk factors.

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Sometimes the simplest things…

I just had a great patient encounter.

An 83 y.o. African American gentleman was referred to me for a creatinine of 1.7 mg/dL (eGFR 50 mL/min). On the initial visit he had a positive review of systems for obstruction. I added a PSA to my normal laboratory work-up of CKD and it ended up grossly positive at 42. We referred him on to urology and they diagnosed prostate Ca. He is currently getting hormone therapy.

Today he came in for his first visit with me since the cancer diagnosis. He was so appreciative. He hugged me. He acted like I saved his life. There was a strange asymmetry to the experience, I felt that I had done almost nothing more than a routine diagnosis while he was treating me like William Osler.

Sometimes the simplest things. . .

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Journal Club: Bicarb for contrast nephropathy and calcitriol for CKD 3 and 4

The first article was a retrospective study on the use of calcitriol in patients with CKD stage 3 and 4. The outcome was mortality and mortality plus dialysis. The authors were able to demonstrate a significant reduction in both outcomes with the use of calcitriol. Some interesting points were the lack of a dose effect and the effect was independent of PTH. The authors suggest that the benefit of activated vitamin D therapy is not due to its affect on PTH.

Association of oral calcitriol with improved survival.

The second article was the latest study on contrast nephropathy.

Sodium bicarbonate vs sodium chloride.

This well done randomized, single-blinded, controlled trial showed no difference between isotonic NaCl and nearly isotonic bicarbonate.

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Journal Club: Albuminuria

Today’s journal club was on Aliskiren (Tekturna)combined with Losartan versus Losartan alone from the NEJM and Benazepril + Amlodipine (Lotrel) versus ACEi + HCTZ (Lotensin HCT) from KI. Both studies use change in albuminuria for the primary endpoint.

The Aliskiren study had an expected outcome. The shocker would have been if it had gone the other way. The surprising thing was how close they came to showing an actual decrease in progression (p=0.07) in only 6 months and with only 600 patients. Looks like aliskiren + ARB is a lock to slow the progression to doubling of creatinine and prevention of dialysis.

The Guard study was a surprise because the old generic lowered albuminuria more than the new hotness Lotrel. A lot of spin in the discussion on why that may have occurred.

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Teaching on Two Ell: Acute Renal Failure and GFR

Yesterday we discussed the problem with the curvilinear relationship between gfr and creatinine and how the MDRD equation dispenses with this problem. Today we will go over a handout introducing GFR, MDRD and how to manage them, including referral to a nephrologist.

Additionally I want to do my canned acute renal failure lecture. This lecture has been made obsolete by the recent ATN data and data from Vanderbilt so it will need to be revised.

ARF No ATN Data

View SlideShare presentation or Upload your own. (tags: arf atn)