1. Adhere to the standard of care for managing CKD.

2. Manage antihypertensive therapy in patients with CKD.

3. Prepare patients with CKD for possible dialysis.

4. Identify the medical indications for dialysis.

5. Implement palliative care for patients with end-stage renal disease.

Medical Management of Chronic Kidney Disease
Brian D. Radbill, MD, Assistant Professor, Department of Medicine, and Clinical Director, Division of Nephrology, Mount Sinai School of Medicine, New York, NY

Kidney functions: regulatory functions—fluid, electrolyte, and acid-base balance; excretory functions— metabolic end-products (urea; creatinine); drugs; toxins; endocrine—renin (blood pressure [BP] regulation); erythropoietin; active vitamin D (1,25 dihydroxyvitamin D3 ; bone metabolism); kidney failure affects many organ systems

Chronic kidney disease (CKD): complications—edema; hyperkalemia; hyperphosphatemia; uremia; metabolic acidosis; hypertension; anemia; hypocalcemia (secondary hyperparathyroidism)

Standard of care for CKD: Kidney Disease Outcomes Quality Initiative (KDOQI) guidelines; include patients with end-stage renal disease (ESRD) on dialysis

Goals of care: prevent progression to ESRD; treat complications of CKD; prepare patients for ESRD; renal replacement therapy—hemodialysis; peritoneal dialysis; kidney transplantation

Preventing CKD progression: focus of care

Factors associated with progression: black ethnicity; decreased nephron number; modifiable risk factors— proteinuria; systolic BP >130 mm Hg; high-protein diet; obesity; anemia; dyslipidemia; smoking; nephrotoxins; cardiovascular (CV) disease (CVD)

Strategies to retard CKD progression: in addition to treating primary cause—angiotensin-receptor blockers (ARBs); angiotensin-converting enzyme (ACE) inhibitors (ACEIs); antihypertensive therapy; low-protein diet; weight loss; erythropoietin-stimulating agents (correct anemia); statins; smoking cessation; nephrotoxin avoidance; optimization of CV function

Antihypertensives: KDOQI guidelines—use ACEI or ARB in patients with diabetic kidney disease, with or without hypertension; use ACEI or ARB in patients with nondiabetic kidney disease, with or without hypertension and with spot urine total protein-to-creatinine ratio of ≥200 mg/g (≈300 mg/day [macroalbuminuria])

Therapeutic considerations: studies found ACEI and/or ARB therapy improved renal outcome; in evaluation of patients with microalbinuria, development of macroalbuminuria used as end point; ACEI and/or ARB use not limited by glomerular filtration rate (GFR); benefits greater in patients with advanced CKD; limitations of therapy—study results demonstrate ACEI or ARB therapy reduces rate of GFR decline, but unable to stabilize or increase GFR; based on study findings, speaker calculates that mean GFR savings 1 to 4 mL/min per year

Management of hypertension: KDOQI guidelines—target BP <130/80 mm Hg

Therapeutic considerations: ACEIs and ARBs first-line agents; in most studies, patients also on diuretics; dihydropyridines (eg, amlodipine) less efficacious and tend to cause or worsen proteinuria; unclear whether lowering BP to <140/90 mm Hg beneficial in black patients or patients with minimal proteinuria

Low-protein diet: KDOQI guidelines—patients with GFR <25 mL/min (stage 4 CKD) require 0.6 g/kg (of body weight) per day; if patient unable to tolerate diet, recommend <0.75 g/kg per day

Therapeutic considerations: high-protein diet may increase GFR and worsen hyperfiltration, causing glomerular injury; study found no benefit from low-protein diet; still controversial; speaker concludes high-protein diet “likely bad,” but very low-protein diet puts patient at risk for malnutrition

Weight loss: obesity and metabolic syndrome associated with development of CKD; little evidence weight loss slows CKD progression; weight loss recommended for reducing CV risk; however, studies show that once patient on dialysis, obesity associated with improved survival (reverse epidemiology)

Erythropoietin-stimulating agents: KDOQI guidelines—target hemoglobin (Hb) of 11 to 12 g/dL

Therapeutic considerations: study found early treatment of anemia (to Hb >12.5 g/dL) may slow progression of ESRD in nondiabetic patients with CKD; more recent studies—showed no benefit from correction of anemia (secondary end point in studies); also found correcting anemia to Hb ≥13 g/dL may increase risk for CV events and death

Statin therapy: KDOQI guidelines—triglycerides <500 mg/dL; low-density lipoprotein (LDL) <100 mg/dL

Therapeutic considerations: some subgroup analyses and meta-analyses suggest benefit of statins in slowing GFR decline; statins recommended for CV risk reduction; optimizing CV function may also improve renal function; study found no CV benefit from statins in diabetic patients with ESRD

Smoking cessation: study followed 92 type-2 diabetic patients for 5 yr (included 39 nonsmokers and 52 smokers); 17% of smokers developed macroalbuminuria; none of nonsmokers and smokers who quit developed macroalbuminuria; GFR decline faster in smokers

Avoiding nephrotoxins: agents to avoid—nonsteroidal anti-inflammatory drugs; aminoglycosides; oral sodium phosphate solutions; intravenous (IV) contrast gadolinium (associated with nephrogenic systemic fibrosis)

Mortality outcomes: study of >1 million Medicare patients found 5 to 10 times greater chance of dying with CKD than progressing to ESRD (CKD increased risk for CV events and death from any cause)

CKD-mineral bone disorder (MBD): systemic disorder of mineral and bone metabolism due to CKD; may account for increased CV event rate in patients with CKD; abnormalities—calcium phosphorous, parathyroid hormone (PTH), or vitamin D metabolism; renal osteodystrophy; vascular or other soft tissue calcifications (especially coronary artery calcifications; associated with increased mortality)

KDOQI guidelines: provide recommendations for treating secondary hyperparathyroidism and hyperphosphatemia in stage 3 to 4 CKD; treatments—low phosphorous diet; phosphate binders (calcium and noncalcium); active vitamin D supplements; possible calcium-mimetic or parathyroidectomy; alkali salts; pearl— hyperphosphatemia occurs late (GFR <40 mL/min); increased CKD mortality actually associated with phosphorus levels in normal range; recent association of higher phosphorus level with increased mortality in non-CKD patients

Priority of goals of care: slowing progression of CKD; CVD risk reduction (greater focus needed); increase patient education about renal replacement therapy for patients more likely to survive

Role of nephrology consultation: patient education on renal replacement therapy; early consultation allows patients more time to plan for dialysis and to discuss various options, eg, renal transplantation; helps primary care physician manage complications of CKD; aids in establishing etiology of CKD; early referral shown to decrease mortality

Questions and answers: preserving veins—important for primary care physician in preparing patient for dialysis; arteriovenous (AV) fistula placed in nondominant arm; avoid IV procedures and central lines in nondominant arm; draw blood only from hand veins; dosages for vitamin D and phosphate binders—main concern vitamin D levels; depend on PTH levels for various stages of CKD; follow recommendations in guidelines; preparation for colonoscopy—speaker advocates testing for undiagnosed CKD before administering phosphate preparation

Dialysis Decisions
Mark A. Swidler, MD, Assistant Professor Department of Medicine, Renal Division, Mount Sinai School of Medicine, New York

Landscape of ESRD and dialysis: those ≥75 yr of age fastest growing group starting dialysis; increases stepwise from 65 yr of age; represents patients (at various stages of CKD) seen in primary care practice

Long-term dialysis: not just treatment for uremia; repetitive process with unique commitments and complications; permanent (unless patient receives transplant); repercussions of serious chronic illness—reduced lifespan; progressive disability; repeated hospitalization; multiple comorbidities; high symptom burden; caregiver stress; trajectory of illness—similar to cancer, frailty syndrome, or dementia; functional decline over months to years; 1-yr probability of death 24%; rate of hospitalization 66%; course uncertain for each patient

Prognosis: CKD risk factor for death from any cause; stepwise increase in death rate, dramatically increasing with dialysis; expected remaining lifetime 10.5 yr in 75 to 79 yr-of-age population vs 2.7 yr in dialysis patients

Adverse geriatric conditions: decreasing GFR <60 mL/min associated with increasing rate of functional limitations, frailty syndrome, and cognitive dysfunction; affect decision about whether patient good candidate for dialysis

Factors determining mortality in dialysis patients: age; low body mass index (BMI; reflects frailty); sarcopenia (decreased muscle mass); malnourishment; inability to ambulate or transfer

Additional concerns: increased rate of hip fracture; dementia limits survival; most vulnerable dialysis patients end up in nursing homes (death rate 3 times rate of ESRD group as whole)

Approach to decisions: decision path—consent to dialysis; withholding, withdrawing, or “forgoing” therapy; time-limited trial; settings—acute renal failure; complications in patient already on dialysis; predialysis patient with CKD stage 4 to 5

Questions to consider: is patient dialysis candidate? what does patient need to know from us? what do we need to know from patient and family?

Four topics method: for analysis of ethical problems in clinical medicine

Medical indications for intervention: ethical basis—beneficence and maleficence (benefits vs burdens); information on prognosis

Prognosis: includes lifestyle and functional level

Patient preferences: ethical basis—respect for autonomy (informed consent)

Autonomy: does not necessarily involve specific decisions about whether to start dialysis; includes patient’s desire not to know problem

Quality of life: ethical basis—beneficence and nonmaleficence; respect for autonomy; no universal criterion

Contextual features: ethical basis—loyalty and fairness (health resources; family dynamics and support)

Medical indications for dialysis: analysis of Medicare database over 9 yr found annual increase in patients ≥85 yr of age going on dialysis (1-yr mortality 46%; relative risk for death 68% higher in those with many comorbidities

Nondialytic treatment: study comparing groups that did and did not go on dialysis found more deaths and shorter survival time in those not going on dialysis; patients with high comorbidity scores fared no better going on dialysis than those who did not; patients with ischemic heart disease failed to increase survival with dialysis

Patient preferences: informed consent (decisional capacity); informed right to forgo treatment; advanced directives; health care proxy; considerations—preferences can change; some patients unable to decide or express preferences; some do not want to receive information and prefer to delegate to others

Quality of life (QOL): no universal measurement; value judgment and personal; objective data include end-stage dementia, cachexia, and advanced cancer; consider time-limited trial to assess QOL on dialysis

Renal palliative care: agreed-upon plan to optimize QOL and relieve suffering (pain and symptom management); offered at same time as other medical therapies; not synonymous with end-of-life or hospice care; not just absence of dialysis; appropriate for all patients with serious illness (high symptom burden; shortened survival; significant comorbidity); multidisciplinary

Components: active treatment of renal complications and symptoms to improve QOL; advanced care planning (ongoing communication to update prognosis, goals of care, and trajectory of decline); family and patient support (creating sense of control; relieving burden; strengthening family relationships); hospice referral (when estimated survival <6 mo)

Start discussions early: to avoid conflict among family members; at CKD stage 4 (GFR 15-29 mL/min; serum creatinine 2.5-3 mg%; ≥65 yr of age); educate patient and family about pros and cons of dialysis; consider transplantation; explore patient preferences with family and friends (talk to health care proxy); use 4-topic method; avoid potential problems—eg, moderate-to-severely impaired decision-making skills in nursing home patients on dialysis (most without advanced care directives)