Chronic Kidney Disease

Improving Patient Outcomes

in the Primary Care Setting

Haerani Rasyid
CNEMU 2018
Chronic Kidney Disease : Why??
1. The rapid increase in the prevalence and the enormous cost of
treatment
2. The discovery of effective measures to prevents its progression
3. An appreciation of its major role in increasing the risk CV
disease
4. Prevalent and clinically silent until its late stages, at which
point patients may suffer significant irreversible damage or
mortality
5. Recent data indicating that overt disease is the trip of an iceberg
of covert disease
 But few are aware of it – even those
with eGFR less than 30

60
Having Weak of Failing Kidneys
Percent Report Being Aware of

50

40
Men
30
Women
20

10

0
eGFR of 30-59 eGFR of 15-29

Coresh, et al., 2007

 Gaps in CKD Diagnosis
CKD Screening in Primary Care
(% of patients)
60

50

40

30

20

10

0
Not Appropriately Tested Appropriately tested - no diagnosis Appropriately tested - accurate diagnosis

% of Patients

Szczech, Lynda A, et al. "Primary Care Detection of Chronic Kidney Disease in Adults with Type-
2 Diabetes: The ADD-CKD Study (Awareness, Detection and Drug Therapy in Type-2 Diabetes
and Chronic Kidney Disease)." PLOS One - In press (2014).
 Individuals at increased risk for CKD should be
tested at the time of a health evaluations to determine if if they have CKD
• Diabetes
• Hypertension
• Autoimmune diseases
• Systemic infections
• Exposure to drugs or procedures associated with
acute decline in kidney function
• Recovery from acute kidney failure
• Age > 60 years
• Family history of kidney disease
• Reduced kidney mass (includes kidney donors and
transplant recipients)
Improved Diagnosis…
Studies demonstrate that clinician behavior changes
when CKD diagnosis improves. Significant
improvements realized in:

• Assessment of microalbuminuria/proteinuria
• GFR = Glomerular filtration rate
• Urinary sediment of urine dipstick for red
blood cells and white blood cells
1. Wei L, et al. Kidney Int. 2013;84:174-178.
2. Chan M, et al. Am J Med. 2007:120;1063-1070
Improved Diagnosis…
 We can have an impact on progression of CKD

• Intensive glycemic control lessens progression from

microalbuminuria in Type 1 diabetes–goal in Type 2 is
less clear
• Antihypertensive therapy with ACE Inhibitors or ARBs
lessens proteinuria and progression
• Blood pressure below 130/80 is beneficial
Early treatment can make a
difference
100

No Treatment

Current Treatment

Early Treatment
GFR (mL/min/1.732)

10
Kidney Failure
0
4 7 9 11

Time (years)
 What can primary care providers do?

• Recognize and test at-risk patients

• Educate patients about CKD and treatment

• Focus on good glycemic control in people with diabetes and

BP control in Ht patients

• For those with CKD:

– Blood pressure below 130/80
– Glycemic control ( Aic < 7)
– Use an ACE inhibitor or ARB
– More than one drug is usually required
– A diuretic should be part of the regimen
What can primary care providers do?
(Continued)

• Monitor eGFR and UACR

• Treat cardiovascular risk, especially with smokers

and hypercholesterolemia

• Screen for anemia (Hgb), malnutrition (albumin),

metabolic bone disease (Ca, Phos, PTH)

• Refer for nutritional guidance

• Consult or team with a nephrologist

• Encourage labs to report estimated eGFR and

urine albumin/creatinine ratios
Why need nutritional guidance ???

TARGET OF NUTRITION MANAGEMENT

 Goals of Nutritional Management

1. To diminish the accumulation of nitrogenous

waste products and the metabolic disturbances
of uremia

2. To ensure that the diet will prevent malnutrition

3. To slow the progression of renal failure

TARGET OF NUTRITION MANAGEMENT
pre-HD Progression 
CKD Malnutrition 

nutrition
management

Chronic Malnutrition 
Dialysis Mortality 
 Nutrition Management .......
A Balanced Approach to Nutrition in CKD:
Macronutrient Composition and Mineral Content*

Low Protein
Low Protein Diet is a Part of diet

Nutritional Therapy in CKD

Adapted from DASH (dietary approaches to stop hypertension) diet.

*Adjust so total calories from protein, fat, and carbohydrate are 100%. Emphasize such whole-food sources as
fresh vegetables, whole grains, nuts, legumes, low-fat or nonfat dairy products, canola oil, olive oil, cold-water
fish, and poultry.

*(CKD Stages 1-4)

NKF KDOQI. Am J Kidney Dis. 2007;49(suppl 2):S1-S179.

1. Adequate adaptation to a reduction in protein
intake
2. Decrease load on remaining nephrons
3. Improve insulin resistance
4. Reduce oxidant stress
5. Ameliorate proteinuria
6. Reduce serum parathyroid hormone levels
7. Improve lipid profile
8. Additive effect of angiotensin-converting-enzyme
inhibitors
9. Decrease likelihood of patient death or delay
initiation of dialysis by 40%
10.Favorable number needed to treat (one patient
saved from death or initiation of dialysis every year
for every 18 patients maintained on a low-protein
diet)
11.Lack of serious objective reasons for not
recommending a low-protein diet to most patients
with chronic kidney disease
Adapted from Fouque & Aparicio., Nature Neph. Reviews 2007
 Low Protein diet
• Delayed Progression PROBLEM

• Malnutrition
 SOLUTION

Maintenance and Adequate and

Reduction of
Improvement of Appropriate
Catabolism
Nutritional Status Nutrient Supply

Low Protein diet +

Ketoanalogue ?

- Prevent Malnutrition
- Delay CKD Progression
- Late initiation of dialysis
Studies of early versus late initiation of dialysis treatment in
CKD patients and in failed kidney transplant patients

Later is better!

Rev
Molnar et al., NatMolnar … Kalantar-Zadeh, Nature Rev Nephrol 2012 With Ketosteril
Nephrol, 2012
If later is better! Try low Protein + Ketoacids
eGRF Advanced Chronic Kidney Disease
25 EARLY Start
Dialysis
20 Higher muscle mass
Better nutritional status

Transplant
Less severe comorbidity Low
15 muscle
mass
10
LATE Start
Dialysis Worse
comorbid
5 Kidney Transplant states
Immunosuppression
Transplant
Infections, urologicals Transplant
Failing Allograft
25

Early Start
Greater 20 -Mix Poorer
15 Case e Outcomes?
Survival? Rac
Late Start
10 Lead Time? Survival?
.
Better 5
Outcomes? Confounding
by Indication?
Hemodynamic Instability
Causal Association? Loss of Residual Renal Function
↑Infection (access related, others)
Biologically Plausible? ↑ Protein Energy Wasting
Anxiety, psychosocial burden

Rev
Molnar et al., NatMolnar … Kalantar-Zadeh, Nature Rev Nephrol 2012
Nephrol, 2012
Wouter et al. Nat. Rev. Nephrol. 2015
Impact of primary care CKD detection
with a patient safety approach

Patient Safety
Following
CKD detection

Improved diagnosis creates opportunity for strategic

preservation of kidney function

Fink et al. Am J Kidney Dis. 2009,53:681-668

 Primary care providers –
First line of defense against CKD

• Primary care professionals can play a significant role

in early diagnosis, treatment, and patient education
• Therapeutic interventions for diabetic CKD are similar
to those required for optimal diabetes care
• Control of glucose, blood pressure, and lipids,
nutrition and others
• A greater emphasis on detecting CKD, and managing
it prior to referral, can improve patient outcomes

CKD is Part of Primary Care

Thanks