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Transcript

 

Lee Tetreault:

Hello and welcome to frequently ask questions from the session, Curbside Consults: Chronic Kidney Disease. We are joined today with Dr. James Pepperello. Doctor, I'm gonna start off with a question that's over-arching and goes over some of the key pointers of today's session: What is your approach to delaying the progression of chronic kidney disease? 

James Pepperello: 

Thank you, and the session that we did today was talking about questions people might have for chronic kidney disease in general. And I think one of the most important things we can do is delay progression of kidney disease, because we don't want any of our patients to need dialysis or transplant. So first and foremost, blood pressure control I think is one of the most important things. Not only does it hopefully help prevent the progression of kidney disease, but it also prevents complications that patients might have, specifically cardiovascular complications like stroke and heart attacks.

After blood pressure control, I also recommend for people with diabetes that they have good blood sugar control. For patients with proteinuria, that'll be a lot of the people with diabetes, they should be on a medicine to help reduce proteinuria, specifically an ACE inhibitor or an ARB, and we specifically address the fact that ACE inhibitor and ARB generally should not be used together. We also recommended that different medications, something like giving sodium bicarbonate for people with a serum bicarbonate level, that's less than 20 in stage 4 or 5 CKD, might help delay progression of kidney disease. And then we also touched upon the new medications, the SGLT2 inhibitors, and how they've been shown to have excellent results, both for renal outcomes and also cardiovascular outcomes that are important to our patients. And one final thing, perhaps most important that often we overlook is, it's a vascular risk factor, including a risk factor for the kidneys. We encourage everybody who is smoking to stop smoking.

Lee Tetreault:

Great. So I wanna get into some of the other frequently asked questions that have come up. First, "Should I worry about a change in GFR based in my treatment of a patient with chronic kidney disease?"

James Pepperello: 

So there's a lot of concern among primary care doctors when the creatinine goes up, and that makes sense. That realizes that the kidney function is getting worse and that patient might be closer to dialysis, and if it's an informed patient, they might say, "Hey, my creatinine is up, I don't like that. Doesn't that mean I'm closer to dialysis?" But what we're realizing more and more is that a rise in creatinine might actually indicate a beneficial effect of a treatment intervention.

Lee Tetreault:

In what instances might a rise in creatinine not be such a bad thing in patients with CKD?

James Pepperello: 

The first thing I caution people is that a small rise in creatinine, such as when we start an ACE inhibitor, of 30% rise in creatinine or less, might actually indicate that the medicine is working well. However, I do worry if that creatinine keeps going up, then we might have to look for other causes of kidney injury, or stop the treatment. But in specific instances, I think one that we're all familiar with, is starting an ACE inhibitor and ARB, a slight rise in creatinine that then stabilizes, it should be followed over time, and perhaps might even get better over time, might be a good thing for prevention of progression of kidney disease.

Other instances where the rise in creatinine might portend better outcomes would be somebody who has heart failure. And so if they're dialyse with their heart failure and they lose a lot of salt and water, and the creatinine goes up a little bit, well that rise in creatinine might simply reflect an increase in creatinine concentration because there's less salt and water in the body. And there would be no reason if the creatinine stays stable and the blood pressure is not low to stop the dialyse, especially if the patient is feeling better, with a better blood pressure control, less swelling, and breathing better.

And then another instance that we learned from the Sprint study is that intensive blood pressure control was associated with AKI, but AKI was defined as a rise in creatinine. So if you have an intervention, which is intensive blood pressure control, which results in reduced cardiovascular events like less heart attacks and strokes, well, a rise in the creatinine level, as long as it stays stable, might be an acceptable trade-off to have that reduce in cardiovascular events. So intensive blood pressure control, if done carefully and without symptoms of syncope or falling, should be a good thing for cardiovascular events and might be associated with a slight rise in creatinine. And then a lot of the buzz today is about the SGLT2 inhibitors, and those also have been shown to cause a rise in creatinine, at least short-term, but a stabilization of GFR over the longer term and a decreased renal outcome event.

Lee Tetreault:

In patients at risk for the acquisition of HIV, should I still consider prescribing PREP if they have a substance use disorder?

James Pepperello: 

Yes, pre-exposure prophylaxis also known as prep, should still be considered for these patients, prep has been shown to be highly effective for the prevention of HIV in persons with ongoing risk factors for HIV or other... For HIV. In a study by Hoenigl and colleagues, they found that Tenofovir drug levels were no different among persons who did or did not abuse alcohol, or among those who did or did not have another substance use disorder, they did find that other sexually transmitted infections, which prep does not protect against were common, especially among those using stimulants. We should still consider prep use among patients with substance use disorders.

Lee Tetreault:

Doctor, what is your take on the blood pressure targets from the ACCAHA 2017 guidelines? 

James Pepperello: 

So it's interesting, when the ACCAHA guidelines came out, they kind of went along with what the AHA was recommending all along, and what they have been recommending since they came out with their lipid-lowering target. So, in people at high risk, it makes sense to be more aggressive with blood pressure lowering. So the fact that they went down to a blood pressure of 130 over 80, and treating those patients who were at high risk to that target, indicates their goal of looking at your high-risk patients and reducing their risk to prevent events. So if you think about it, a lot of people, if hypertension and blood pressure measure on a bell shaped curve, there's gonna be a lot more people with blood pressures the more you get towards the mean. So, somebody with a blood pressure of 160 is at high risk, but there's hopefully less people with that number. As you get down to 130 systolic blood pressure, there's gonna be a lot more people with that number. The risk is lower than somebody at 160, but because there's a lot more people, there's a lot more potential events that can be prevented.

So looking at those patients in that range, and seeing if they're at high risk, and bringing their blood pressure down is reasonable. I think a lot of us who treat patients, particularly older patients, worry about side effects, and I think side effects, particularly in older patients, are something that have to be considered. And one of the best ways to address this is to get some home blood pressure measurements, and if the blood pressure is truly high at home, then I think a reasonable discussion with your patient to try and lower the blood pressure to the target you pick, whether it's 130 or 140 over 80 or 90, assessing the benefits of blood pressure control, which is usually a reduction in cardiovascular events versus the risk of the medication is warranted.

Lee Tetreault:

And lastly, doctor, how do you approach discussing renal replacement therapy in patients who have progressive chronic kidney disease?

James Pepperello: 

So one of the big issues that patients come in when they see a nephrologist and they know they have kidney disease is: "Do I need dialysis?" And the good news for many of those patients is that most patients with CKD don't progress to needing renal replacement therapy. However, in those patients who do progress to needing renal replacement therapy, I think the discussion has to be open-minded and a shared patient-physician decision-making model, with the physician guiding them with their knowledge about the options. And so I think the first thing to discuss is does the patient want renal replacement therapy or not? 'Cause some patients if they have a lot of co-morbidities, may not want to choose renal replacement therapy.

Then the next question is, are they a transplant candidate or not, and is that something they're willing to pursue? And if that is, that should be pursued. Then the next question is, if they're not a transplant candidate, and they do want renal replacement therapy, how do they wanna dialyse? Do they wanna dialyse at home or do they wanna dialyse at a center? And you can go through the pluses and minuses of in-center dialysis, where it's three times a week for three to four hours of treatment. They have to get there and get home, but otherwise, everything is taken care for them versus a home modality. And there's two types of home modalities. There's peritoneal dialysis, which is a modality that people can do at home, either a few treatments a day or one overnight. And then there's also home hemodialysis where patients can get a dialysis treatment at their home, usually administered by a family member who's well trained, and they can get that treatment for two to three hours, three to five times a week, depending on their need. So a lot of these choices end up being more a lifestyle and preference choice for the patient, who needs to be educated about what their options are.

Lee Tetreault:

This is great information, doctor. Thank you so much for your time today.