CKD Transition to Hemodialysis (Cheung, 1/29/2020)

Thanks so much to Dr. Eric Cheung, nephrologist, who delivered a FABULOUS Grand Rounds on the Transition from Chronic Kidney Disease to Dialysis, which he described as akin to falling down the rabbit hole—and a strange one at that. Dr. Cheung’s presentation was tremendously informative and extremely practical. . .and he even had some good jokes.    

 Dr. Cheung shared with us the global trends regarding dialysis. While center-based hemodialysis (HD) is much more common in the US (90% of US pts), home peritoneal dialysis (PD) is much more common in developing countries (it’s cheaper and requires less infrastructure). Interestingly PD rates are also quite high in Hong Kong (80%) where ALL patients are mandated to start dialysis on PD. In general the highest rates of dialysis are in the wealthiest countries. Both the US and Japan have a slightly lower incidence of new dialysis over the past decade which is reassuring.

 In the US, there are 468,000 patients on dialysis, and 193,000 with a “functional transplant”.

Fortunately there are several minority groups who have a decreasing trend in the need for dialysis over the last decade: 15% lower in Blacks, 24% lower in American Indian/Alaska Native, 17% lower in Hispanic, and 11% lower in females. (We hope this is because of improved prevention and education!)

 One area we need to improve in is telling our patients they have CKD.  Of patients who have CKD 1-3 (who are thus asymptomatic), less than 10% know they have CKD. For patients who are CKD stage 4, only 45% know they have CKD. Yikes!

There are several types of transition from advanced CKD:

• Advanced CKD -> dialysis
• Advanced CKD -> pre-emptive transplantation
• Changing dialysis modalities (HDà PD, PDà HD)
• Failed transplant -> dialysis
• Dialysis -> transplant
• Withdraw of care from dialysis (which leads to death in about 7-10 days)

And don’t forget that no initiation of dialysis is an option- just conservative management


Categorizing patient risk for progression from CKD to dialysis:

• High Risk Patients: any patient with Diabetes (but especially those with proteinuria), uncontrolled HTN, CHF, cirrhosis, >60 years old, and Polycystic CKD.
• Lower Risk Patients: AKI with recovery (i.e. Sepsis, cardiac arrest, dehydration, obstructive uropathy), ironically Polycystic CKD (really based on family history—if

There is an online calculator to help! https://kidneyfailurerisk.com/


Does it help to start dialysis early (GFR 10-14) vs late (GFR 5-7)? 

• The IDEAL study for ASYMPTOMATIC patients with CKD shows us that there is NO difference in mortality. So…
• if the eGFR is >15 or is 5-15 without symptoms -> monitor (of course with the help of your friendly neighborhood nephrologist)
• if the eGFR is 5-15 with symptoms or <5 -> start dialysis

Initiation of dialysis is risky!  Especially the first several months—7-10x increase in death (even over all dialysis patients who already have a high mortality)!

Cardiovascular and infectious causes are major causes of increased mortality. Indications to initiate dialysis include:

• Absolute indications: uremic encephalopathy, uremic pericarditis/pleuritic
• Common indications: declining  nutrition/appetite, fatigue/malaise, mild cognitive impairment

Ideally, initiation starts gradually with advanced planning including setting expectations and getting long-term access coordinated (see below).

However, some patients need to start HD in the hospital – if no other option, poorly controlled HTN or hypotension, active angina, hx of seizures, or lack of social support.


Hemodialysis Access:

• AV fistula is preferred and often lasts the longest and is basically a direct connection of the artery and vein in the forearm. Greatest risk of clot in the first month but thereafter clots are uncommon. Can last decades.
• AV graft needed sometimes in vasculopaths and connect the artery and vein, but tends to clot when no longer in use.
• Central venous catheter/tunneled cath: definitely least preferred but often used in transition. It is inserted into the internal jugular (NEVER the subclavian due to risk of stenosis), double lumen 14-16 french.

TIPS from your friendly nephrologist for primary care providers:

Medications to avoid/adjust:

• DM: ask CKD progresses, pts generally need less insulin needed because it hangs around longer; ALWAYS stop metformin when GFR <30 to avoid lactic acidosis; and d/c thiazolidinediones
• HTN: as CKD progresses, stop ACE/ARBs (but after they start on HD they are great HTN meds)
• Seizure/Pain meds: avoid gabapentin and baclofen which have toxic metabolites in CKD/ESRD
• Antibiotics: Bactrim/Septra – don’t use in CKD patients since the SMX component can cause hyperkalemia; Cefipime can accumulate (care with this!)

Preserve the Veins in your CKD patients long BEFORE they may need dialysis!

• ·         Avoid subclavian lines
• ·         Avoid PICC lines and midlines as much as possible
• ·         For phlebotomy, use dorsal veins of the dominant hand instead of AC fossa

And last but not least. . .What is Dr. Cheung’s personally preferred form of dialysis? (and hopefully he never needs it!)….HD at HOME!  (yes, this is actually an option). Rare but has lower mortality and complications than HD at centers

Lower Extremity Ulcers (D'Costa, 1/22/2020)

Thank you to Dr. D’Costa for 40 years of service to our community AND for an informative Grand Rounds this week on lower extremity ulcers.

I’m sorry for those of you who missed the presentation also missed the photos—what Dr. D’Costa finds “beautiful”, frankly I find a little nauseating. 

Also, thanks to Dr. Grierson (Dr. D’Costa’s new partner) for a bonus presentation on Charcot Foot, which will heretofore be on my ddx for diabetics presenting with a red, hot, swollen foot

Here are a few things to remember from both Dr. D’Costa and Dr. Grierson’s presentations: 

• ~9.4% of US population has diabetes (that is over 30 million people
• 6% of Medicare patients with diabetes develop an ulcer annually
• There is a 19-34% lifetime risk of developing a foot ulcer with diabetes
• Over 50% get infected
• 20% of moderate to severe diabetic foot infections get amputated

There is a 70% mortality at 5 years after an amputation, and 74% mortality at 2 years if on hemodialysis. This rivals 5 year rates of death from colon cancer

3 major types of lower extremity ulcers: neuropathic, vascular (arterial and venous), and “other”

You SHOULD culture an ulcer if you suspect infection: but do a DEEP WOUND CULTURE to avoid normal skin flora, also tissue or bone sample is best

Be on the  lookout for absent hair, atrophic skin or nails, dependent rubor, calf pain with walking

Neuropathic ulcers:

Caused by the combination of insensitivity (sensory loss) and pressure

• As neuropathy progresses, the intrinsic muscles of the foot are more and more affected, leading to claw toes and other deformities, often with  ulcers forming under metatarsal heads
• Usually painless, on plantar surface
• Pressure points: metatarsal head, medial hallux, lateral 5th toe
• Rimmed with callus (which needs to be de-bulked to offload)

Venous ulcers: Incompetent valves allow backflow leading to venous hypertensionà increase in interstitial fluidà mast cell inflammationà edema

Also occur in stasis states (e.g CHF), s/p saphenous vein harvesting for CABG

• Trophic skin changes: thinning of skin, drying of skin, hemosiderin deposition
• Ulcer usually moist and weeping fluid
• Can be present for years/decades
• Prevention includes hydrating skin, diuretics, elevation of limb, elevation of limb above heart at rest, venous pumps
• Treatment: create moist wound environment, but also absorb excessive drainage (calcium alginate, silver-impregnated gauze)
• Abx if needed, also biopsy if no improvement to r/o vasculitis vs. malignancy

Ischemic ulcers: Usually occur due to lack of vascular supply  (e.g. PVD, PAD)

• Poor man’s test: Capillary refill (>4 seconds), absence of DP and TP pulses
• Can be extremely painful

Osteomyelitis: infection of bone due to seeding from outside source

• Requires break in skin (e.g. ulcer) or penetrating wound (e.g. nail or insulin)
• You must r/o hematogenous spread if there is no open lesion on the foot
• Bone biopsy is gold standard to diagnose

Charcot foot: neuropathic arthropathy, under-recognized and underreported

• Acutely presents as RED, HOT, swollen foot (similar to gout, cellulitis, VTE)
• Subacute: foot and ankle deformity
• Have to distinguish between osteo/cellulitis and Charcot—which can be tricky
• MRI is sensitive but not specific
• Bone scan is good non-invasive option
• Otherwise bone bx is diagnostic

Behavior Change and Lifestyle: The Hot New Drug (Brown, 1/15/2020)

Thank you to Dr. Ben Brown for a motivational Grand Rounds this week on behavior change and lifestyle as “the hot new drug”. 

We are 16 days into the month, and I am still on track with my New Year’s resolution to exercise more. How’s your lifestyle goal going? Read on if you need a little motivation.

Dr. Brown’s pearls:

Lifestyle changes lead to measureable improvement and meaningful outcomes. For real.

• Weight loss, cholesterol-lowering, blood pressure, HbA1C, depression scores
• Lifestyle change prevents, stabilizes and even reverses heart disease
• Lifestyle changes lead to downregulation of cancer oncogenes (yup!)

Medicine operates under the assumption that “Taking a pill is easy, lifestyle change is hard.

• That isn’t exactly true. Unfortunately, studies show that less than 1/3 of patients after an acute event are taking their statin at 6 months
• BUT in supportive lifestyle change programs, adherence is as high 87% at one year (it actually feels good)

Which “lifestyle changes” is Dr. Brown talking about? Four pillars:

o   Exercising (at least 150 minutes/week)

o   Not smoking

o   Eating a healthy diet

o   Keeping a healthy weight (normal BMI)

It’s not rocket science, people, BUT that doesn’t mean it’s easy. A large Mayo Clinic population study found :

o    11.1% of participants met NONE of the above criteria,

o   33.5% had one

o   36.8% had two

o    16% had three

o   ONLY 2.7% of adults met all FOUR healthy lifestyle criteria

If you or a patient is interested, intensive lifestyle management is actually a covered benefit under Medicare (specific dx include ACS, CAD s/p CABG or PCI, CHF, valvular abnormalities);

• Dean Ornish program in Marin: 415-927-6172 (Max Drake, program director), closest to Santa Rosa

Hey Doctors, it’s time to WALK THE WALK!

·         Physicians who perform aerobic exercise regularly are MORE likely to counsel patients about aerobic exercise (Clin J Sport Med, 2000)

·         Physicians who eat healthy are more likely to ask about dietary practice, advise about dietary practices, an ASSIST PATIENTS in making changes (Preventive Med 2002)

Ben’s advice: keep it simple

1) Pick a single action (e.g. exercising regularly)

2) Establish a (reasonable) floor and a (ideal) ceiling (e.g. 15 minutes a day is my floor, 1 hour a day is my ceiling)

3) Set a Time and place (e.g. starting tonight 9pm, after I put my kids in bed, living room. Anyone want to join?)

Methamphetamine Use Disorder (Nicholson, 1/8/2020)

Thank you so much to Dr. Lisa Nicholson for her excellent presentation this week during Grand Rounds on Methamphetamine Use Disorder.

Most of you are well aware that methamphetamine has some health effects and societal implications, but did you know that our very own health care system and pharmaceutical companies are responsible for introducing methamphetamine to our military pilots in WW2 (to keep them awake), to the general market OTC in 1939 (brand nameBenzedrine) and is still available even today with a prescription?

Meth has been marketed for the treatment of depression, obesity, fatigue, low libido, inattentiveness, menopause, nasal congestion, asthma, and even the common cold. (Check out the ads to the Right) 

Methamphetamine is typically smoked, inhaled, or ingested. In California, the majority of people who use meth smoke it, but in Texas, the majority inject it.

·        1.2% of Californians have used meth in the last year

·        6% of Sonoma County 11^th graders have tried meth (yikes!)

·        Meth is the most common illicit substance used worldwide (after MJ)

·        In Sonoma County, meth is by far the most commonly used substance in families involved with the Sonoma County court system implicated in the abuse or neglect of children (second to alcohol)

This is MIND-BLOWING! Meth is the most addictive substance that exists: 47% of people will become addicted after first use, 60% after second use

Medical implications of meth use:

·        Acute intoxication: malignant hypertension, stroke, cardiac arrest, meth psychosis

·        Post-meth: altered mental status, irritability, violence

·        Long term: meth cardiomyopathy, dental problems, cerebral atrophy, mood disorders

A bit on Meth psychosis. . .

·        Up to 40% of users get meth psychosis, it is dose dependent, on average 1 week duration, but users with >5 years of use can have prolonged psychosis (>1 month).

o  If a patient has experience meth psychosis in the past, they are “sensitized” and more likely to experience it again in the future

·        Meth psychosis can mimic other mental illness: mania, schizophrenia, mood disorders.

o  At Zuckerberg SFGH inpatient psych facility estimates 47% of patients admitted to the inpatient ward are not mentally ill—they are high/coming down from meth (2019 study)

·        To distinguish primary psychosis from meth induced: you must have meth use BEFORE psychosis, and abstaining from meth likely will improve/make recede the psychosis

·        There is limited evidence on the use of atypical antipsychotics for thetx of meth psychosis: generally olanzapine, quetiapine. There is also evidence for the use of benzodiazepines for the treatment of meth withdrawal

A bit on hypertension. . .

Severe hypertension of meth should be treated with BETA BLOCKERS: labetolol. Tachycardia can be treated with  metoprolol (correct the catecholamine flood)

Patients with severe hypertension and chest pain are at risk for acute MI, dissection, and/or aortic aneurysm. Get a head CT if you cannot examine them thoroughly.

Meth cardiomyopathy very common (usually dilated non-ischemic, VERY low EF ~10%).

A 2017 German study found that with meth abstinence average EF increased from 20% to 43%, so STOPPING METH can improve cardiac function markedly!!!

There are no FDA approved treatments for meth use disorder. Mixed evidence for:

·        Bupropion (Wellbutrin): blocks dopamine reuptake, can help in early abstinence, modest evidence, not recommended after 4 weeks abstinence (can be triggering)

·        Mirtazapine: helps with sleep, appetite, modest reduction in meth use

·        Naltrexone: appears to decrease meth high and cravings, mixed results

·        Modafinil (Provigil): some evidence in cocaine use disorder, 2010 RCT said no better than placebo for meth

·        Adderall/Ritalin: jury still out

      

Psychosocial approaches:

Best evidence in non-pharm management of patient is for contingency management (=monetary or other tangible short term rewards for abstinence)PLUS Community reinforcement (healthy restructuring of social environment)

Not great evidence for 12-step, CPT or supportive therapy. Hmmm. No one in Sonoma County appears to currently be using contingency management—MediCal does Not cover it

Don’t forget harm reduction in patients with meth use disorder:

1)     Condoms 2) PrEP 3) Needle exchange (when appropriate) 4) Dental Care 5) Clinic structures that don’t punish people for no-shows, tending more to drop-in