Take control of chronic kidney disease with tools, and tips from @kidney_boy, Joel Topf, MD Salt Whisperer and Chief of Nephrology at Kashlak Memorial Hospital. Learn which equation is best for eGFR, how to counsel patients about progression/prognosis, how to monitor patients in CKD, and who needs a referral to Nephrology. Special thanks to Annie Medina, and Justin Berk for writing/producing this show and to physician-artist, Kate Grant for her lovely and hilarious artwork (more at paintscientific.com).
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Case from Kashlak Memorial:Donald is a 56 year old African American gentleman with heart failure, hypertension, diabetes, and chronic kidney disease been seen as a new patient. He doesn’t take any medications as he just recently got his insurance back. Shoutout to Kashlak social work team! His creatinine today is 1.7, which seems to be his baseline.
What equation should be used to estimate GFR?CKD-Epi. Based on largest population of any calculator. Best for “normal sized people.”
24 hour urine creatinine clearance equation works for all patients regardless of size e.g. bodybuilder, or amputee. Can be corrected for body surface area (click link) [Urine Cr (mg/dl) * Urine volume (ml)] / [Plasma Cr (mg/dl) * Time (min)] = CrCl
How does age affect GFR? Controversial – adults are expected to lose approximately 1 ml/year of GFR past age 40.
CKD 3: Twice yearly visits for urinalysis (UA), urine albumin:creatinine ratio (ACR)
CKD 4: Four times yearly visits for UA, ACR, plus annual hemoglobin, PTH
Low protein diet in CKD is controversial: UpToDate suggests possible benefit, but many Nephrologists (like Dr Topf) disagree with this interpretation of the data. Read this for more insight
Most common form of anemia is iron (Fe) deficiency, not Epo deficiency elevated hepcidin → poor iron absorption, patients may need IV iron
Treating secondary hyperparathyroidismlacks evidence for clinical outcomes like fracture. Consider therapy w/activated vitamin D if PTH level rising >150-200 consistently due to development of treatment resistance w/symptoms of bone pain, itching, fractures
Goal: Listeners will gain a better understanding of the diagnosis and management of chronic kidney disease and the associated complications
Learning objectives: After listening to this episode listeners will…
Diagnose and risk stratify chronic kidney disease
Perform an initial workup and evaluation for new patient with CKD
Identify possible interventions (pharmacological, dietary, and other) to slow CKD progression
Utilize formulas to estimate GFR and Creatinine Clearance.
Explain CKD to patients and counsel them on prognosis
Identify the secondary complications caused by CKD and how to address them
Identify patients who need a referral to nephrology
Disclosures: Dr Topf lists the following disclosures on his website:
“I am on the speakers bureau for Astute Medical. I have an ownership stake in four Davita run dialysis clinics and one vascular access center. Astellas paid for my trip to Australia (Feb ’15) for me to speak at one meeting and three hospitals. Takeda Oncology made a donation to MM4MM the program that is taking me to Mount Everest in 2018.”
03:13 Pick of the weeks
08:49 Clinical Case
09:36 How to explain CKD to patients
12:16 Loss of GFR with age
13:22 Which equation should be used to estimate GFR
18:05 Creatinine clearance from 24 hour urine collection
22:25 Initial workup upon diagnosis of CKD
25:40 Interpreting tests for proteinuria
26:52 Staging and prognosis in CKD
32:00 Completing the initial workup for CKD
33:52 Who needs a referral to nephrology?
35:53 What labs to check in CKD and a discussion of secondary hyperparathyroidism
Hi! Tried to access Joel Topf's Nephrology Update 2017 and the link appears to be not working - wonder if his site crashed with all of us curbsider fans trying to access it?! Thanks!
Excellent podcast. I learned many things except for the one thing I was looking for. How should a primary care provider dose medications for patients with decrease renal function and for patient’s who are going through dialysis? Please look at the drug augmentin at epocrates. Please look at the renal dosing section and have someone explain that clearly, as one would describe to a newbie. Also, what should one do in a clinical / office setting where CrCl is not able to be obtained? https://online.epocrates.com/drugs/420/Augmentin
Matt, I received your response through email. Thank you for responding to me.
Hi - How the guest doctor describes how he calculates the example equation with the twenty four hour creatinine clearance and then verbally runs through an example are two different things. One one he is saying to divide by the number of minutes in the day and the other he says to multiply by the number of minutes in the day. Could you please post the correct equation? Thank you! :)