Presentation Transcript

1. Philip J. Goushaw, MD Renal Associates of West Michigan

   What Primary Care Physicians Need to Know About ESRD

2. Disclosures None
3. General Principles ESRD patients differ from the general population in several ways: Increased cardiovascular complications Different drug metabolism Different risk profiles for pharmaceuticals Important dietary considerations Dialysis access considerations
4. All-Cause Mortality Deaths per 1000 patient-years at risk Patient Age Adapted from the USRDS Annual Data Report, 2013
5. Expected Remaining Lifetime USRDS Annual Data Report, 2013
6. ESRD Mortality vs Other Dx USRDS ADS, 2013
7. Causes of Death Adapted from the USRDS ADR, 2005
8. ESRD Cost
9. Case #1 A 62 yo♂ with ESRD due to chronic GN, on HD x 3 yrs recently had an episode of CP with elevated troponins and was diagnosed with NSTEMI. C-cath reveals 2 vessel dz and medical therapy is recommended. Lipid studies show T. Chol 185 mg/dL, LDL 117, HDL 36, TG 138. Cardiology recommends atorvastatin 20 mg/d, but the patient reports muscle pain with simvastatin in the past which necessitated its discontinuance. Which of the following statements is NOT correct?: Statins have not been shown to decrease CV events or deaths in ESRD pts The use of a statin in this patient is not indicated because of the lack of proven efficacy in trials as well as his history of rhabdomyolysis with statins Uremic dyslipidemia is characterized by a shift in LDL particle size to small dense LDL; statin therapy does not alter LDL particle size There is a higher incidence of dyslipidemia in PD > HD patients Combining statins + fibrates increases the risk of myalgia and rhabdomyolysis in hemodialysis patients..
10. Case #1 A 62 yo♂ with ESRD due to chronic GN, on HD x 3 yrs recently had an episode of CP with elevated troponins and was diagnosed with NSTEMI. C-cath reveals 2 vessel dz and medical therapy is recommended. Lipid studies show T. Chol 185 mg/dL, LDL 117, HDL 36, TG 138. Cardiology recommends atorvastatin 20 mg/d, but the patient reports muscle pain with simvastatin in the past which necessitated its discontinuance. Which of the following statements is NOT correct?: Statins have not been shown to decrease CV events or deaths in ESRD pts The use of a statin in this patient is not indicated because of the lack of proven efficacy in trials as well as his history of rhabdomyolysis with statins Uremic dyslipidemia is characterized by a shift in LDL particle size to small dense LDL; statin therapy does not alter LDL particle size There is a higher incidence of dyslipidemia in PD > HD patients Combining statins + fibrates increases the risk of myalgia and rhabdomyolysis in hemodialysis patients
11. Case #1 - Discussion Die Deutsche Diabetes DialyseStudie (4D Study) NEJM 2005; 353:238-248
12. Case #1 - Discussion Aurora Study NEJM 2009; 360:1395-1407
13. Statins in ESRD - Summary Not indicated for routine usage May be beneficial in secondary prevention Currently no data to support statin withdrawal for those already on therapy for primary prevention as long as they are asymptomatic
14. Case #2 A 54 year old man on HD x 5 years has undergone a carpal tunnel release surgery. You prescribe a narcotic for pain relief. Which of the following is INCORRECT? A dose reduction of at least 50% is required for narcotic initiation in dialysis patients Metabolites of meperidine and propoxyphene accumulate in renal failure and should be avoided in ESRD patients Evidence of narcotic toxicity in ESRD patients includse nausea, myoclonic jerking and delirium Pain after carpal tunnel surgery should be manageable by acetaminophen alone..
15. Case #2 A 54 year old man on HD x 5 years has undergone a carpal tunnel release surgery. You prescribe a narcotic for pain relief. Which of the following is INCORRECT? A dose reduction of at least 50% is required for narcotic initiation in dialysis patients Metabolites of meperidine and propoxyphene accumulate in renal failure and should be avoided in ESRD patients Evidence of narcotic toxicity in ESRD patients includes nausea, myoclonic jerking and delirium Pain after carpal tunnel surgery should be manageable by acetaminophen alone
16. Case #2 - Discussion Most narcotics should be dose-adjusted for ESRD patients by decreasing the dose 50%. Further titration may be necessary Meperidine, propoxyphene, and tramadol should be avoided in ESRD patients. Codeine and morphine should be used with caution Acetaminophen can typically be used safely in ESRD Evidence of narcotic toxicity in ESRD can mimic uremic neuropathy (altered mental status, myoclonic jerking, etc.)
17. Medications in ESRD Some commonly mis-dosed medications include: Gabapentin – 100% renal clearance. Start dosing at 100-300 mg three times per week, following dialysis treatments Allopurinol – 25% of usual dose Zantac/Pepcid – 10-25% of usual dose Reglan – 50% of usual dose Statins – 50-75% dose-reduction for most statins ACE inhibitors – 25-75% of usual dose Most antibiotics require renal dosing Avoid: metformin, Mg+, tetracyclines, certain antivirals, fenofibrate, sucralfate (and all Al-based medications), phosphate-based enemas It’s impossible to know them all – so look it up if not sure!!!
18. Case #3 A 43 yo ESRD pt has been scheduled for an MRI with gadolinium (Gd) contrast to assess a suspicious renal mass seen on an abdominal ultrasound. Which of the following is FALSE regarding nephrogenic systemic fibrosis (NSF)? No cases of NSF have been reported in patients with a GFR > 60 ml/min Radiologic societies recommend to never use gadolinium as a contrast agent in ESRD patients as the best way of avoiding NSF The differences in incidence of NSF with different Gd products is most likely due to variance in usage of those agents The risk of NSF has not been shown to be lowered by prednisone before and after exposure..
19. Case #3 A 43 yo ESRD pt has been scheduled for an MRI with gadolinium (Gd) contrast to assess a suspicious renal mass seen on an abdominal ultrasound. Which of the following is FALSE regarding nephrogenic systemic fibrosis (NSF)? No cases of NSF have been reported in patients with a GFR > 60 ml/min Radiologic societies recommend to never use gadolinium as a contrast agent as the best way of avoiding NSF The differences in incidence of NSF with different Gd products is most likely due to variance in usage of those agents The risk of NSF has not been shown to be lowered by prednisone before and after exposure
20. Case #3 - Discussion Gadolinium Contrast agent used to increase MR signal intensity
21. Gadolinium Pharmacology Gd3+ has an ionic radius ≈ Ca2+ and thus competes with Ca2+ in biologic systems Can interfere with neuromuscular transmission Gd3+ enhances the polymerization rate of collagen by binding to the collagen helix The elimination of GBCA’s is dependent upon the GFR
22. NSF – Clinical Presentation Thickening and hardening of the skin, decreasing ROM Fibrosis of the dermis and, often, burning pain Often mistaken for scleroderma or cellulitis
23. NSF – Clinical Presentation The latent period between exposure and manifestation is typically 2-4 weeks The changes are progressive and permanent
24. NSF – Risk and Treatment ESRD: 2.5 – 5.0%: Avoid GBCAs if possible CKD 4/5: increased but ill-defined risk: Avoid GBCAs CKD 1/2/3: No reported cases, avoidance not needed Treatment: None! Prevention is key! If cannot avoid in high-risk groups, then daily high-flux dialysis x 3 is recommended
25. Case #4 A 72 yo male with a history of ESRD from diabetic nephropathy, on HD for 7 years, presents to the ED with chest pain, dyspnea and diaphoresis. A cardiac catheterization is scheduled and the cardiologist requests a dialysis run after the procedure to remove the contrast load. Which of the following is TRUE regarding the use of iodinated contrast media in HD patients? Iodinated contrast media can cause tissue necrosis if not removed within 48 hours via native or mechanical renal clearance There is no contraindication for the administration of iodinated contrast in most chronic hemodialysis patients Prompt, post-procedural, high-flux dialysis can reduce the incidence of acute kidney injury from iodinated contrast agents If not removed, an iodinated contrast load will typically lead to the development of decompensated congestive heart failure..
26. Case #4 A 72 yo male with a history of ESRD from diabetic nephropathy, on HD for 7 years, presents to the ED with chest pain, dyspnea and diaphoresis. A cardiac catheterization is scheduled and the cardiologist requests a dialysis run after the procedure to remove the contrast load. Which of the following is TRUE regarding the use of iodinated contrast media in HD patients? Iodinated contrast media can cause tissue necrosis if not removed within 48 hours via native or mechanical renal clearance There is no contraindication for the administration of iodinated contrast in most chronic hemodialysis patients Prompt, post-procedural, high-flux dialysis can reduce the incidence of acute kidney injury from iodinated contrast agents If not removed, an iodinated contrast load will typically lead to the development of decompensated congestive heart failure
27. Case #4 - Discussion The primary, nonanaphylactoid reaction associated with IBCAs is AKI/CIN (2-7% of total uses)J Am SocNephol. 1994;5:125-137 One study suggesting prevention of CIN after IBCA exposure in CKD patients via hemofiltration was seriously flawedN Engl J Med 2003;349:1333-1340 Contrast induced nephropathy (CIN) occurs immediately upon exposure. Most studies examining the effect of postcontrast dialysis have not revealed prevention of CIN or benefit to the patient Some studies have found prophylactic HD after contrast exposure to be potentially harmfulAm J Med 2001; 111:692-698 Am J Roetgenol1994; 163: 969-971 Nephrol Dial Transplant 1998: 13:1051 Nephron 1995; 70:430-437 Nephrol Dial Transplant 1998; 13:358-362
28. Case #4 – Discussion Take home messages: Residual renal function can be important in some ESRD patients If a patient is anuric or oliguric, this is a non-issue HD or CRRT after IBCA exposure does nothing to prevent CIN HD or CRRT itself can pose certain risks to the patient If volume overload is a concern, HD may be indicated following IBCA exposure, but this is not a common situation
29. Case #5 A 34 yoESRD patient, on HD for 3 years, goes to a summer party following his 4 hour dialysis treatment. He appears to tolerate his HD run well. At the party, he has dinner, consisting of some tropical fruit salad, three helpings of roasted pork and a baked potato. He has 2 rum & cola drinks as well as coconut cream pie for dessert. After returning home, his spouse calls 911 after witnessing him having severe hiccups followed by a grand mal type seizure. Which of the following is the MOST likely cause for his seizure? Acute alcohol intoxication Hyperkalemia from his dietary indiscretion Acute uremic reaction from excessive meat ingestion A neurotoxic effect from the fruit salad contents Delayed, type-B dialyzer reaction..
30. Case #5 A 34 yoESRD patient, on HD for 3 years, goes to a summer party following his 4 hour dialysis treatment. He appears to tolerate his HD run well. At the party, he has dinner, consisting of some tropical fruit salad, three helpings of roasted pork and a baked potato. He has 2 rum & cola drinks as well as coconut cream pie for dessert. After returning home, his spouse calls 911 after witnessing him having severe hiccups followed by a grand mal type seizure. Which of the following is the MOST likely cause for his seizure? Acute alcohol intoxication Hyperkalemia from his dietary indiscretion Acute uremic reaction from excessive meat ingestion A neurotoxic effect from the fruit salad contents Delayed, type-B dialyzer reaction
31. Case #5 - Discussion Star fruit (Averrhoacarambola) is a popular tropical fruit in many Asian and South American countries. It has a substance which may act as a neurotoxin in ESRD patients. Symptoms include: hiccups, seizures, coma and/or death! Dialysis patients are told to avoid even a piece of this fruit The toxin is dialyzable and symptoms resolve with HDNeto et al, Nephrol Dial Transplant 2003, 18 (1): 120-125
32. ESRD and Diet Malnutrition in ESRD is strongly linked to poor outcomes The typical “renal diet” is HIGH protein The renal diet can be quite restrictive/difficult to follow: The usual recommended fluid intake is < 2 liters/day The usual potassium restriction is < 2 grams/day The usual phosphorus restriction is < 2 grams/day Dietary phosphate binders need to be taken with meals in order for them to work
33. …and this dish is totally potassium and phosphorus-free!
34. Summary ESRD patients require special consideration in several areas of medical care Many routine medications, treatments and dietary options pose special risks to ESRD patients Most ESRD patients are not well represented by the “frequent fliers” you see every other week in the hospital Due to the high mortality in this population, err on the side of caution when they call with problems Your nephrology colleagues are only a call away!
35. Teamwork:“None of us is as smart as all of us”