00:01
Okay,
so it's not all doom and gloom
when it comes to
chronic kidney disease.
00:05
We've talked about the risk
factors for progression
and that there are
certain populations
who are going to progress
more than other people
but although there is
progressive nephron loss
and we can't
necessarily avoid that.
00:16
There are some
interventions that we can do
in order to slow the
rate of progression
and help our patient
and it's critical to
understand what those are.
00:24
Let's move on to a clinical case
in order to
illustrate our point.
00:28
So you're seeing a
56 year old gentleman
who has stage 3A
chronic kidney disease
due to diabetic nephropathy.
00:34
His physical exam is remarkable
for a blood pressure
of 148 over 90.
00:39
His serum creatinine is 1.4
milligrams per deciliter.
00:42
We see that that's elevated
and it gives them
an estimated GFR
a 50 mils per minute
provided by ckd-epi.
00:49
He has over proteinuria
estimated at 402 milligrams
by spot
albumin-to-creatinine ratio
so we can see that
that's elevated as well.
00:57
And as hemoglobin A1c
is 6.5 percent on insulin
taking both lantus and novolog.
01:04
So the question is
what is the next logical step
in the management
of this patient CKD?
Let's go through
our clinical case
and see if we can
answer that question.
01:16
So one of the things to look at
are his risk factors
for progression.
01:20
Remember,
he has diabetes mellitus,
which is one of those diseases
that actually progress
kidney disease.
01:27
And he's a male gender.
01:28
So those are two risk
factors that we think about.
01:30
He also has uncontrolled blood
pressure and proteinuria.
01:34
So these are all
concerning things
that can accelerate his risk
for disease progression,
but I think what's interesting
is that is hemoglobin A1c,
which is measuring is diabetes
is actually quite controlled
on his current therapy at 6.5%.
01:47
So again,
what's the next logical step
in the management
of this patient CKD?
We can either add
an oral hypoglycemic
like glipizide in
efforts to reduce his A1c
to less than 6%.
02:01
We can add a calcium channel
blocker like amlodipine
to effectively control
his blood pressure
and suppress his albuminuria,
or we can add an ACE inhibitor
in order to control
both as blood pressure
and suppresses albuminuria.
02:14
Which one do you think it is?
Well, let's go through them.
02:19
If we added an oral hypoglycemic,
does that make sense?
Remember,
He's already on insulin therapy.
02:24
His A1C was well controlled.
02:26
I would love to have a patient
who had an A1C of 6.5%
So there's really no data
that reducing A1C below 7%
is going to improve outcome.
02:35
So we know number one is wrong.
02:37
Number 2. should we add a calcium
channel blocker like a dihydropyridine
like amlodipine took
control of blood pressure?
Well, that's not correct either
and although dihydropyridine calcium
channel blockers are wonderful
at controlling blood
pressure amlodipine is huge
in my armamentarium for
blood pressure agents.
02:54
They don't suppress albuminuria,
and that's what we're
trying to target
in addition to blood pressure.
03:01
So adding an ACE inhibitor
or an ARB Angiotensin
receptor blocker
can not only help to control
this gentleman's blood pressure,
but it can suppress the
albuminuria by antagonizing
the renin-angiotensin system
helping to reduce proteinuria
and slow the progression
of this gentleman's chronic kidney
disease and that's what we want to do.
03:23
Okay,
let's move on to interventions
that can slow the progression
of chronic kidney disease.
03:28
One of the most
important interventions
is having good blood pressure
control in our patients.
03:33
So our goal blood pressure
in our patients is less than
125 to 130 systolically,
over less than 80 diastolicly
using standard routine
clinician office measurements.
03:45
Now when our patient is at home,
and they're doing either home
blood pressure measurements
or continuous ambulatory
blood pressure monitor.
03:53
That go lowers a little bit
because they're in their
natural environment.
03:57
So that goal blood pressure
really should be less than
120 to 125 for a systolic
and less than 80
for a diastolic.
04:04
Now it's interesting
because lower goals
have been proposed
for people who have
a vert proteinuria
to even less than 125 over 75,
but really when
looking at the data,
there's no convincing data
to really support this
so really our goals are
what I've outlined above.
04:22
Now another intervention that
we can do to slow progression
is use use of
renin-angiotensin-aldosterone Inhibitors
or RAAS antagonism.
04:30
So medications
like ACE inhibitors
or Angiotensin receptor
blockers are very important.
04:35
They can slow progression
of chronic kidney disease
in patients who
have proteinuria.
04:40
So again,
those patients who have albumin
greater than 30
milligrams per day
or their protein levels of greater
than 150 milligrams per day.
04:46
It's critical to have
these medications on board.
04:51
And Remember,
it's interesting
because ACE inhibitors
and ARBs have an
independent effect
independent a blood
pressure lowering
that really helps our
patients in terms of
reducing the progression
of their disease.
05:02
And again, if you think about
kind of how these agents work,
they decreased glomerular
capillary pressure.
05:08
Why is that?
Because they're working on
the efferent arteriole, right?
They cause vasodilation there
and that lowers the
glomerular capillary pressure
and in so doing that's going
to reduce hyperfiltration
and it also has actions to mitigates
tubulointerstitial fibrosis,
so these drugs are really
critical in our patients
particularly who have
protein direct diseases.
05:28
Sodium-glucose cotransporter 2 (or SGLT2) inhibitors
can be used for individuals with chronic kidney disease and proteinuria, even in the absence of diabetes.
05:41
These drugs act by blocking absorption of glucose in the proximal tubule,
leading to excretion of glucose in the urine. Additionally, they have multiple renoprotective effects,
including reducing intraglomerular pressure and hyperfiltration,
which can help reduce proteinuria and renal function decline.
06:02
Other interventions that can help
are controlling phosphorus levels.
06:05
Remember how we talked
about phosphorus
and how it stimulates
that FGF-23.
06:09
So we want to ensure that
phosphorus levels are low.
06:12
So we ask our patients
for dietary discretion.
06:14
We advise them what foods
are high in phosphorus
and they have to be
very cognizant to ensure
that they don't take too
much of those foods in
things like dairy and nuts
and high protein meals.
06:25
We also can use agents
like phosphorus binders.
06:28
So these are big giant pills
that are patient has to take
either before or
right with the meal
and that actually
binds the phosphorus
and eliminates it through stool.
06:37
But it is very cumbersome
for a patient to do
sometimes these
patients are taking four
or five binders at each meal.
06:44
So I do want you to be cognizant
when you're asking your
patients to do things
how difficult sometimes it is
for them to do this.
06:52
We want to treat their
metabolic acidosis.
06:54
Remember, these people develop
acid base abnormalities
because they end up
with a decrease decrease
in the ability to handle acid
so we can give them things like
sodium bicarbonate
supplementation,
and we just talked about
before how that's been shown
to slow the rate of
loss of GFR over time.
07:09
So it's an important
area to really correct
and we want to counsel our
patients to stop smoking.
07:15
I cannot underscore
how important it is
to really approach your
patient holistically
and really help with
lifestyle modification.
07:22
I give all the resources
possible to my patients
whether they're smoking
cessation groups
whether there are people
that they can talk to you
about quitting smoking.
07:30
This is critical
to really help them
in terms of preventing
their disease progression.
07:35
We can correct their anemia.
07:36
Remember we talked about how
our patients have a decrease
in Epo production
from their kidney.
07:41
We can actually give
them a erythrocyte
stimulating agents or
ESA like Epoetin alfa.
07:47
That actually helps to
produce those red blood cells.
07:49
So they don't have to
feel anemic and terrible.
07:52
We're very clear about
when we want to start this
so we don't really start this
until that hemoglobin is less
than 10 grams per deciliter
and we want to maintain
that hemoglobin
between 10 and 11.5
grams per deciliter.
08:02
The reason being is that
if we were to ever correct
that hemoglobin to the
higher or normal range
that patient might be at
risk for either neoplasms
or an increase in
cardiovascular events.
08:11
So we do have tight
control of their anemia
when they're on these ESA's.
08:16
We also want to
think about using
HMG-CoA reductase
Inhibitors or statins.
08:21
Remember our patients typically
have lipid abnormalities
and using statins
may be associated
with slowing of GFR,
but they're important
again to reduce
these cardiovascular risks
that are really prevalent
in our patient population.
08:35
We also want to
counsel our patients
to have a lower protein diet.
08:39
The benefit is really seen
more in proteinuric diseases.
08:42
So in patients who tend to have
greater than 1 gram of protein
in their urine per day.
08:46
And there's a potential
in that patient population
to slow the rate of
loss of GFR over time.
08:52
The goal that we usually achieve
or what we try to strive for
is about 0.6 to 0.8 grams
per kilogram of protein per day.
09:00
That's not a lot of protein.
09:01
So in that case,
I usually have my
nutritionist involved
so that they can follow
my patients to ensure
that the protein that they're
eating is high quality
and that they don't
become malnourished.
09:12
Another important aspect
is to treat the actual
underlying disease.
09:17
So if I have a diabetic,
I've got to have strict
glycemic control.
09:20
I want that blood glucose
or hemoglobin A1c
to be less than 7%,
because we know by
randomized controlled trials
that is going to result in
improved renal outcomes.
09:30
And for my patients who
have glomerular diseases
other than diabetes,
then I want to think about
immune targeted therapy
or immunosuppression to treat
that underlying disease.