Quality Insights: I'll wait just a second because it doesn't look like there anyone has logged in yet.
Quality Insights: Um, which is a little odd. So let me
Quality Insights: see. I'm wondering if they
Quality Insights: having the pass code.
Kristi Krug: Did you have to have a passcode to get in, Doctor?
Dr. Asif Rahman: No.
Dr. Asif Rahman: Okay. I have the trouble.
Dr. Asif Rahman: They asked me for a pass code which I thought was
Dr. Asif Rahman: actually.
Quality Insights: I am going to pause the recording just for a moment.
Christopher Henry: Can you hear me?
Christopher Henry: This meeting is being recorded.
Quality Insights: Yes, I can. I was just curious, Chris. If you had gotten a pass code
Quality Insights: we are recording this Webinar, so we will be able to.
Quality Insights: We'll be able to share this recording with everyone as well.
Quality Insights: So those that might have had trouble getting logged in. They will get a link to the recording whenever we get finished.
Quality Insights: Okay,
Quality Insights: Well, good afternoon, everyone. I apologize for a few technical difficulties there at the beginning, but we're ready to get started. I wanted to welcome you to Today's webinar on spilling the beans on kidney care chronic kidney disease.
Quality Insights: So we'll get started in just a couple of minutes. But I want to um talk about just a few housekeeping items. First of all, anyone that is attending right Now, has entered Today's Webinar in listen-only mode.
Quality Insights: So if you have a question or a comment during today's call, we just ask that you please type that into either the chat or the Q. And a box which should be located at the bottom of your zoom window. You may need to hover your mouse around the bottom of that window to get the icons to appear.
Quality Insights: Um,
Quality Insights: Also,
Quality Insights: we have some great information that we're going to be delivering to you today, and so without further ado, What i'm going to do is turn things over to Kristy Krue. She's a quality improvement specialist here. Quality insights, and she is going to be introducing Today's Guest Speaker and
Kristi Krug: Hi, everybody. I'm Kristy crew, quality, improvement, specialist for quality insights, and i'm glad you all could join us today. Um as we talked about chronic kidney disease, and it is my pleasure to introduce our guest speaker today. Dr. Uh, he's a clinical specialist in hypertension and clinics professor of medicine with Kawa. Ha! I can't say it, or how
Kristi Krug: private practice in nephrology
Kristi Krug: and hyp it all.
Kristi Krug: How is it?
Dr. Asif Rahman: Canola? Canala, Private practice in nephrology and hypertension in Charleston West Virginia? Thank you for joining us today, Doctor.
Quality Insights: Okay, Dr. Rama, whenever you're ready.
Dr. Asif Rahman: Okay, i'm ready. So I I hope everybody can hear me, because Christy's voice was sort of bubbling through the
Dr. Asif Rahman: through the mic. But hopefully you can hear me clearly and and welcome. And you
Dr. Asif Rahman: I can hear you. Well,
Dr. Asif Rahman: well, that's really. I think I spoke too soon. It was just a second.
Are we there?
Quality Insights: Yes,
Dr. Asif Rahman: okay. While you are trying to figure out how to move the slide forward. I'll say that I live, breathe, and sleep chronic. Give me the
Dr. Asif Rahman: um very dear, that's
Dr. Asif Rahman: for I signed up for in one thousand nine hundred and ninety-
Dr. Asif Rahman: and that's what i'm,
Dr. Asif Rahman: he said, that this is going to be an in,
and as relevant
Dr. Asif Rahman: Dr. Raman I think we lost my,
Dr. Asif Rahman: and that we are having problems or something else.
Quality Insights: Um, anyway.
Dr. Asif Rahman: Well, you're your audio. So we have a question. A thirty, two-year-old woman is being a bet.
Oh,
Dr. Asif Rahman: Oh,
Dr. Asif Rahman: I can hear you.
Quality Insights: Okay, I can't. I can't really hear you For some reason, Dr. Ram and I apologize.
Quality Insights: Okay, Let's Let's try this one more time. Okay, you're ready to. Am I on the right slide? I think we're having some connection issues here. I apologize.
Dr. Asif Rahman: You're in the right.
Dr. Asif Rahman: This
Dr. Asif Rahman: in this case I will run away to some other room to see if the connection the
Dr. Asif Rahman: then you um it's it's breaking up a little bit. Kristy. Is it breaking up for you. Is it just me?
Kristi Krug: Yes, it's breaking up here as well.
Dr. Asif Rahman: You don't care. I will move over to another room.
Dr. Asif Rahman: Please bear with me. I apologize for this.
Quality Insights: No problem.
Quality Insights: I think that everyone is having a few technical difficulties today, myself included.
Dr. Asif Rahman: Can you hear me better now?
Quality Insights: Yes,
Quality Insights: um.
Quality Insights: Now Now it appears to be completely frozen.
Kristi Krug: It's been
Kristi Krug: you,
Quality Insights: Dr. Roman, If you can hear us, we cannot hear you, and it appears that your camera is frozen as well.
Quality Insights: I think you're muted right now, but I do see you
Dr. Asif Rahman: unmute. All right. I think this is gonna work perfect. Thank you so much. I appreciate your patience.
Dr. Asif Rahman: No, I I apologize. Okay, Jumping where I left off thirty, two-year-old woman is being evaluated during a new vacation visit. She's healthy exercises regularly without symptoms and takes no medications. Medical history is un remarkable. Family history is notable for a father and paternal, and
Dr. Asif Rahman: who both have hypertension and chronic kidney disease. There is no family history of polycystic kidney disease. A father begun, began dialysis when he was fifty years old, and now has a kidney. Transplant physical examination and vital signs are normal. Which of the following should be done to screen for chronic kidney disease.
Dr. Asif Rahman: Give you exactly three and a half seconds to figure that out
Dr. Asif Rahman: Hit the button
Dr. Asif Rahman: next. There you go, so see them creating. So so we figure out the first test to do
Dr. Asif Rahman: in the evaluation of a patient who we are thinking may have chronic in the disease is check a blood work for acetum creating, and I'll get to this estimated Gfr business, and a your analysis. So that is the first thing we don't want to
Dr. Asif Rahman: go. Very fancy just one blood test, one year analysis. It's all we need to try to figure out what's happening
Dr. Asif Rahman: next.
Dr. Asif Rahman: So chronic kidney disease affects ten to thirteen percent of the adult Us. Population with increased risk for and stage drinking disease, cardiovascular death, disease and death. Actually, here is a little tidbit.
Dr. Asif Rahman: Five percent of the medicare budget. Five percent of the billions and billions of money that medicare spends every year is towards the care of the end-stage renal disease, population, which means dialysis,
Dr. Asif Rahman: and They are very, very, very interested in us stopping, preventing, postponing,
Dr. Asif Rahman: flowing down the progression of being the disease. So it is not only the right thing to do; it is monetarily helpful to also know and and know how to treat and slow down. Give me disease. And the second sort of says that
Dr. Asif Rahman: that's exactly what I've said. That dramatic filtration rate after the age of forty we lose about one percent kidney function for each year of life or ten percent for every ten years of life after the age of forty. So if we can,
Dr. Asif Rahman: that is accelerated for some reason, we need to slow that down.
Dr. Asif Rahman: See them creating and protein and the urine are surrogates of kidney damage, and I will come to that again and again, as one of my mentors used to say, creatnine is a measure of kidney function
Dr. Asif Rahman: and protein, and the urine is a measure of kidney damage. So the moment we have protein in the urine we know that something in the kidney Perenn Kema has been damaged while acetum creatine is a measure of kidney function.
Dr. Asif Rahman: Okay,
Dr. Asif Rahman: So see them creating what is that? It is a by-product of muscle breakdown. It's production every day is balanced out by how much you get
Dr. Asif Rahman: by excretion. So the amount we make is,
Dr. Asif Rahman: it should equal the amount we excrete, and we remain in a steady state balance. So if we start producing more as an exercise, or we are aligned back up to the Wbu Mountaineer football team, we make more, or we have muscle damage, we make more. So we make much more creating that our kidneys may be able to get rid of that one day in our see them creating will rise, and the other thing is, we are making the same amount.
Dr. Asif Rahman: But our kidneys are damaged, and now we are excreting less in our ceremony, we will go up. So an elevated seed of Crete should be
Dr. Asif Rahman: viewed in this sense. Are we making more? Are we excreting, less excreting less is a problem, right?
Dr. Asif Rahman: We used to do twenty four, our urine collections to see how much is coming out. We don't do that anymore. We
Dr. Asif Rahman: just check acetum creating and estimate what is called a glue medal of filtration, and i'll get to that in the next couple of slides, and we check. We don't check any more. A twenty four urine
Dr. Asif Rahman: protein excretion. I told you that protein and the urine is a sign of kidney damage. We do a protein to create the racial. So all we need is ten milliliters of urine, and we can check it for a random protein level and a random reacting level, and we can have a racial and the ratio as long as it is the low a certain level. We'll get to that less than three hundred. We're, we're good to go. Our human is the same thing as humans. We're doing very short,
Dr. Asif Rahman: less than thirty good to go. We are completely normal next.
Dr. Asif Rahman: So chronic kidney disease, freedom, creation, is not sufficiently accurate on which to various decisions. I just gave you an example where the scene of creating can be elevated without any damage to the kidneys, as in a large individual with a high muscular mass; and the opposite is also true. If you
Dr. Asif Rahman: amputate both my like legs. My muscle mass has suddenly decreased, so my creaking would be falsely low. Right so estimation of the blumen of filtration. Ray is the best overall index of the level of kidney function.
Dr. Asif Rahman: You can have changes in your Gfr. Even before your seed of creativity starts, dries. So a Gfr is the proper way to
Dr. Asif Rahman: estimate where somebody's kidney function is today, and then you follow that over the next year, five years, ten years rest of their lives, and you have a trend which is the most important thing in the treatment of chronic in the disease. It's the trend. It's not where we start. It's where we are headed, and that is what we need to slow down right where we are headed. So a trend is what we need next.
Dr. Asif Rahman: There we go,
Dr. Asif Rahman: not I. I just want you to notice this. There are two formulas by which we calculate your glomerular filtration rate. One is called the Kafka and Gore, equation, and that is the equation that all pharmacists
Dr. Asif Rahman: use to base their drug dosing. On the basis of this it uses a person's age, A person's rate their sex, and they see them creating, and they come up with a number and based on that number. They do all the drug dosing because
Dr. Asif Rahman: it was the first equation, and for the last fifty years it was available. And that's where all the studies were done. So they never moved down to the next equation which is called the Mdr. The modification of diet and renal disease equation, which is a little more complicated. But thankfully, every single lab in the country now spits out a number for us, right? It spits out, and all we use for that is
Dr. Asif Rahman: age, your sex, and you see them create me until about six months ago. We used to use race in this equation, but that has been eliminated. So we just need an age,
Dr. Asif Rahman: the sex and the freedom, creating, as you can imagine, the age changes, the
Dr. Asif Rahman: and and your Gfr. Will change as long as you see them creating remains stable right. But if the age is changing and the creating is changing. Then we are in double trouble, right? And we have a little bit of under
Dr. Asif Rahman: overestimation and an underestimation. But That's a pretty close
Dr. Asif Rahman: check on what your glamorous filtration is. So all we need is a sedum cre acting plug it in the labs, fits our number, and that's your grammar of filtration next
Dr. Asif Rahman: based on them, based on that, We have divided people into five stages. Now,
Dr. Asif Rahman: here is the
Dr. Asif Rahman: clincher.
Dr. Asif Rahman: You have to have kidney damage or evidence of kidney damage for three months or more. Right if it is less than three months. It is called acute kidney injury. Right? So. A Crete name that is changing from day to day to day to day
Dr. Asif Rahman: is not chronic. That's in a cube. It's either a cute kidney injury or a recovery from acute to me injury. If it is falling, so we should not face anything. So we should have a stable triad mean for three months or more, which is abnormal before we can say somebody has chronic any disease that's number one.
Dr. Asif Rahman: So once we have established that somebody has chronic disease, we say, What kind of kidney disease is it? A systemic illness? Is it a illness related only to the kidney, and so on, so forth? And finally, the severity of your of the kidney disease based on the Gfr.
Dr. Asif Rahman: Here we go on the Gfr. Which is stage One is above ninety milliliters per minute stage two is sixty to ninety. Stage three is thirty to sixty. Stage four is fifteen to thirty, and stage five is less than fifteen.
Dr. Asif Rahman: So here is
Dr. Asif Rahman: the next step
Dr. Asif Rahman: stage. Three or greater stays, three, four, or five just uses the blametral filtration rate.
Dr. Asif Rahman: Define chronic kidney disease, stage three, four hundred and five,
Dr. Asif Rahman: stage one and two requires not only a Gfr number, but it also requires a marker of kidney damage. What does that mean, Marker, that something has gone wrong
Dr. Asif Rahman: that is protein in the urine that is Wbc's or Rvcs in the urine you do a
Dr. Asif Rahman: X-ray or a Ct scan or an ultrasound of the kidneys, and that is abnormal, or there is renal tubular acidosis. There are other chemistries that are abnormal. So stage one and two require, and at markers of kidney damage in addition to just the number. So you could have, for example,
Dr. Asif Rahman: a diabetic
Dr. Asif Rahman: whose Gfr. Is one hundred and forty, and yet they have protein in the urine. They already have stage, one chronic kidney disease, and that's why there is a different between difference between one, two, three, one, two, and three, four, five, right, so three, four, five. The moment you don't need any
Dr. Asif Rahman: markers of kidney damage you are at forty, five Gfr. You got stage three kilometers seas.
Dr. Asif Rahman: Next,
Dr. Asif Rahman: they have further divided, stays three in full, mild, and moderate, which is stage three,
Dr. Asif Rahman: a, which is forty to fifty, nine, whether it's H. Three B is thirty to forty, four. So it's sort of expanded upon that, whereas three A. May not be at such a high risk, or for the worst thing, because
Dr. Asif Rahman: patients were freaking out. Oh, my! On stage three can be disease. Meanwhile my Gf. Is fifty nine. No calm down. Everything is all right. Everything will remain all right. So they have divided that between three A and three. B. So there's just a little bit of a division there
Dr. Asif Rahman: next
Dr. Asif Rahman: who should be evaluated here
Dr. Asif Rahman: when when you are out in in in in the public, and you're seeing patients, all individuals should be assessed at routine health encounters. Now, all you need is to see them creating right. All. All. All you need is the same priority, and who are at the increased risk,
Dr. Asif Rahman: older than fifty diabetes, hypertension, and cardiovascular disease. These are the people,
Dr. Asif Rahman: and and this is a pretty standard thing to do a Dmp. And do a your analysis. And as you can see a blood pressure management. The B Andp will give you a seed of pre-appropine, a random urine a tendil later. Little Your analysis thing for a protein to create being racial or an algorithm for creating ratio and a your analysis which will tell you whether somebody has dipstick protein. They'll tell you whether somebody has
Dr. Asif Rahman: any blood in the urine, whether somebody has any other formed elements, tasks in the urine or something, because those are the markers of give me damage. So here we have who should be evaluated, and how should they be evaluated? Right age older than fifty diabetes, high attention, cardiovascular disease. I can throw in people with a family history of renal disease also, just to make sure.
Dr. Asif Rahman: So if anybody amongst this audience is curious about themselves, all they have to do is check your blood pressure, do a B and be to check your pre a name and do your analysis, and and you will have a
Dr. Asif Rahman: great idea as to where you stand on your Ckd spectrum right
Dr. Asif Rahman: next.
Dr. Asif Rahman: Here's about the question. The sixty nine year old man is evaluated during a new patient visit. They are coming to you. Medical history. Twenty-three years year, history of partner, attention, and kidney stones for about fifteen years. Family history is is a mother, who began dialysis at the age of seventy, two years for unknown reasons, and died of kidney disease. Five years later. Medications are licensed and died of kidney disease. Five years later medications are licensed and died of kidney disease. Five years later medications are licensed and died of kidney disease. Five years later. Medications are licensed
Dr. Asif Rahman: twenty, two, our trade seventy, two breathing forty, fourteen times a minute, and Bmi is twenty nine not too bad, and the rest of the exam is normal. Creating is one point. Nine. One year ago it was one point eight, six years ago. It was one point four. We see a trend. Gfr is thirty, seven
Dr. Asif Rahman: hemoglobin, twelve, your analysis two plus protein zero to two Rbc's, two to four Wbcs and urine culture. No growth.
Dr. Asif Rahman: As we are evaluating this the Your analysis of two-plus protein already tells me that is kidney damage. Creatin is a measure of kidney function. Protein. And the urine is a measure of kidney damage
Dr. Asif Rahman: zero to two Rbc's is acceptable in a your analysis. Two to four Wbc's is acceptable.
Dr. Asif Rahman: You're in culture. There's no growth. So there is no infection
Dr. Asif Rahman: we now have that six years ago the cre acting was mildly elevated one year ago. It was one point eight, and now it is one point nine. Remember, Gfr. Is measured by aged sex, and you'll see them creating as the cedom reacting, goes up.
Dr. Asif Rahman: The Gfr. Falls down. So six years ago it probably was a lot higher than the thirty seven that is being measured Now, right? So what is the next most appropriate test that we have do for this individual.
You get three seconds to think the answer
Dr. Asif Rahman: next slide,
Dr. Asif Rahman: Kidney ultra-stenography, right? So, kidney biopsy we always talk about all the abnormal, all the wrong answers. The kidney biopsy is reserved for people who you suspect of having an acute glumetalone of Fridays,
Dr. Asif Rahman: where the biopsy results are going to change your treatment right. If you already know somebody has given me disease, and you have a fairly good idea that there is nothing else you can do by obtaining a kidney biopsy. There is no point of obtaining
Dr. Asif Rahman: a kidney biopsy because it is not without risk, Right? An abnormal see to, with contrast, exposes the individual with chronic in the disease to Ib contrast which in itself
Dr. Asif Rahman: can cause contrast and use their property. So unless you're going to change something that is no need to do that right.
Dr. Asif Rahman: A radio nuclear kidney care and scan is done, usually in children, and it is a way to compare kidney function from the right side to the left side. That is the best way of telling.
Dr. Asif Rahman: Ah, with a what is a nuclear scan in the kidney. So a kidney ultrasonography gives us several pieces of information. It tells us whether the kidneys are wrong.
Dr. Asif Rahman: It tells us whether kidneys are shrunk. It tells us where the kidneys have tumors, cysts or stones, or any other irregularities. So a killed kidney ultrasound, and it is totally and completely benign with most side effects. Right? So that is the first test
Dr. Asif Rahman: that you should be doing in a patient that you diagnosed with chronic kidney disease. Okay, next
Dr. Asif Rahman: very busy slide, which just says something. And I need you to focus on the blue on the green and the middle grade. And as you can see that as and this is seen,
Dr. Asif Rahman: people with all human to creating racial right, and the blue is
Dr. Asif Rahman: over three hundred milligram for Graham. The
Dr. Asif Rahman: The green is less than thirty milligram, and this is showing that your cardiovascular mortality is lowest in the people, with the lowest amount of alumin to create being racial, the higher the protein in your urine, the greater the cardiovascular
Dr. Asif Rahman: mortality right so faster. Same thing for end-stage renovations, and same thing for progressive ckd so the
Dr. Asif Rahman: at an e gfr of sixty a patient with the
Dr. Asif Rahman: an album to create the ratio of three hundred milligrams as an eight-fold increased trans of having progressive kidney disease, and in state real disease, that one for thirty milligrams. That's the that's the key thing. Protein in the urine is bad protein, and the urine has to be controlled. Protein and the urine
Dr. Asif Rahman: causes the highest level of cardiovascular disease, highest level of disease and and progressive Ckd: So the moment you establish somebody as protein, and you have quantitative that with a protein to create a ratio. You've got to control that. That's an individual risk factor. So I just wanted to make that point for the slide next.
Dr. Asif Rahman: Here is another way so on the left-hand side we have G. One G. Two, that that that's your Ckd stages, one two three a threed and four and five, and, on the other hand, on the top, you have a human to creating. Racial.
Dr. Asif Rahman: Less than thirty is normal. Thirty to three hundred is moderately and over two thousand is is horrible right? And these are the people who are at highest risk. So you can have stage one chronic kidney disease with
Dr. Asif Rahman: over two thousand milligrams of albumin for creating, and the risk of developing kidney failure is the same is the same as somebody with stage five kidney disease and very little protein in the Europe. That's how important proteinuria is, because I keep telling you
Dr. Asif Rahman: is a measure of kidney function. The
Dr. Asif Rahman: proteinuria is a measure of kidney damage. So the more the protein, the more the kidneys are damaged, the higher the risk of dying with heart disease and kidney disease. I hope I made my point come through through the waves of this computer
Dr. Asif Rahman: next
Dr. Asif Rahman: which one of the following individuals is more likely to have progression of his or her Tkd to the point of requiring renewed replacement therapy, which is another moniker for dialysis of our transplant rather than dying prior to initiation, or we know replacement therapy a forty, four year old. Caucasian female, with high intensive. Give me disease, Gfr. Of sixty, five.
Dr. Asif Rahman: You're an argument to create a ratio of two hundred. Next one is a fifty, eight year old, Caucasian male, with diabetes, Gfr. Of sixty, five, and an album to create a ratio of thirty,
Dr. Asif Rahman: a seventy, five year old African-american male, with diabetes in a property Gfr. Of fifty, five and then alumin to create to make sure of thirty a fifty year old African-american male, with hypertensive kidney disease,
Dr. Asif Rahman: Gfr. Of fifty, five, and an album to create a ratio of one thousand five hundred milligrams of brand. The
Dr. Asif Rahman: three seconds later.
Dr. Asif Rahman: Next,
Dr. Asif Rahman: of course, right? So I have made myself forced telling you about how dangerous. So it is. Not only the Gfr. It is the Gfr. With the high levels of protein that are at highest risk for developing cardiovascular and real progression of renal disease next
Dr. Asif Rahman: so
Dr. Asif Rahman: felt, who are at increased risk. What are you doing there right? What do you do with these people so slow? The progression of chronic kidney disease? And we'll go through all of these individually, and then manage the complications of C. Kd. Right? So the first thing is, control the blood pressure
Dr. Asif Rahman: next.
Dr. Asif Rahman: So when you are doing blood pressure, control all blood pressure medicines are not created equal Right? How much to control the blood pressure if they are one hundred and eighty systolic. So we bring them down to one hundred and sixty. Is that enough? Or where should we end up right presence of the
Dr. Asif Rahman: degree of protein of human extrusion and the choice of antibiotics? So those are the three things that we need to do so. All studies so far
Dr. Asif Rahman: are summarized in this formal line, currently a target of one hundred and thirty over eighty in patients, for a Ckd. Is better, for you know protection than a higher level. In the presence of Bomberia. One hundred and thirty over eighty should be your primary goal.
Dr. Asif Rahman: One hundred and twenty or below should be your secondary goal, right? And here is what i'm going to say. Something that will shock. Maybe some of you is the ability to push
Dr. Asif Rahman: lower and lower blood pressures has been found more
Dr. Asif Rahman: the inertia of the provider than actual hesitance on the part of the patient. What am I trying to say? Is
Dr. Asif Rahman: we the providers, see a blood pressure that we have successfully brought down from one hundred and sixty to one hundred and thirty five systolic.
Dr. Asif Rahman: We are all happy, but we should not be happy with that. We need to bring it down, Lord,
Dr. Asif Rahman: once we our primary goal, less than one hundred and eighty and secondary goal, even lower, as long as the patient can tolerate it right as long. So if I come to you as a patient with chronic in the disease, bring my blood pressure down to one by teams of stalling
Dr. Asif Rahman: as long as i'm not orthostatic, and i'm not falling down and breaking my head right so so that is the key thing. So the primary goal, less than one hundred and thirty started next slide
Dr. Asif Rahman: a forty-seven year Old Man is evaluated during a follow-up visit for stage three chronic in the disease medications are licensed to the licensee and glyposite creatine is one point. Seven Gfr is forty, one. All the other things are pretty normal. You're protein to create ratio is good.
Dr. Asif Rahman: Which of the following changes to this patient's therapeutic regiment. Remember, we are talking blood pressure. His blood pressure was one hundred and forty, eight over eighty two. What should we do
Dr. Asif Rahman: sodium bicarbonate again activated vitamin d therapy. We increase anti hypertension therapy or no change. That was the
Dr. Asif Rahman: provider inertia I was talking about the
Dr. Asif Rahman: next
Dr. Asif Rahman: increase anti-hypetence of therapy. We all know that our primary goal is to break it down below one hundred and thirty over eighty, next
Dr. Asif Rahman: a fifty-seven year old male
Dr. Asif Rahman: twenty years of hypertension
Dr. Asif Rahman: he has had a weight gain of four point five kilos in the past six months does not smoke cigarettes.
Dr. Asif Rahman: Only medication is chlorophylledone blood pressure high, one hundred and forty, six to one hundred and fifty over nineteen. Emi is twenty, nine, part two to seventy. Eight remainder of the exam is normal. Gfr. Is fifty one,
Dr. Asif Rahman: as you see, I've skipped talking about creativity, and I. I talked about Gfr. Because we all understand what that is which of the following is the most appropriate next step in the managing of this patient,
Dr. Asif Rahman: the next.
Dr. Asif Rahman: Okay. So we are going to come to this now add license. April or no Sarton right
Dr. Asif Rahman: next,
Dr. Asif Rahman: Brass blockers, also called Rennin Angiotensin, Aldostrom system blockers. They treat high blood pressure. They decrease protein and they slow. The progression of Ckd.
Dr. Asif Rahman: Grass blockers are your number One best friends in the treatment of
Dr. Asif Rahman: by itself, so you can have high blood pressure without Ckd. Use raspberries. You can have procureia without ckd or pipeline pressure. Use dress blockers. You can have Ckd without Rad, but
Dr. Asif Rahman: Nuria used rass blockers. Your brass blockers are your friends in the kidney world, right in the kidney world. Next
Dr. Asif Rahman: the four
Dr. Asif Rahman: groups are
Dr. Asif Rahman: the Ace Inhibitors, the Angiotens and receptor Blockers, the direct Grenin inhibitors and the aldosterone antagonists. These are all raspberries. I can eliminate
Dr. Asif Rahman: the direct Drennan inhibitors. They are on the market, but we just have stopped using them right between aces and arms. They have been found to be totally equivalent in their effectiveness,
Dr. Asif Rahman: and I use arms exclusively for the simple reason It doesn't cause a cough. Thirty percent of your patients with Ace in a bitters will develop a cough, and you will be switching them to an arm right. So why not just start them on an arm
Dr. Asif Rahman: right off the back right? So that is why I have stopped using ace inhibitors at completely.
Dr. Asif Rahman: I try to change the patients who come to me on as in the better, as to an arm, so that I want to prevent. Also, there is a decreased incidence of angioedema with arbs when compared to Aces right and allosterone antagonists are an add-on therapy two aces in arts. Right so for me it is arts and I lost for antagonist
Dr. Asif Rahman: one type of raspberry pi, but better than another, I just said that they are equivalent. What is the optimal dose? What is the highest amount of those that they can tolerate. I don't in your in your
Dr. Asif Rahman: so that, for example, low-sarten
Dr. Asif Rahman: you start with twelve and a half, you can go to a hundred.
Dr. Asif Rahman: No point going to five hundred, because you will not have any added benefit of that is using more than one class of raspberries together, more effective in retarding Ckt progression. The news in one loan
Dr. Asif Rahman: A's art fuss, aldosterone, antagonist, Yes, cases and arts together absolutely not contrindicated, caused an increased risk of aki and hypercalmia and death. Right so do other medications added to Raspberry's health, or into the impact of these drugs. We cut that just a second
Dr. Asif Rahman: next.
Dr. Asif Rahman: My son helped me make the slide. Our blood pressures are a combination of cardiac output. Times vascular resistance, cardiac output is the squeeze of the heart,
Dr. Asif Rahman: the volume and the heart rate right the
Dr. Asif Rahman: then there is the systemic. So we need to control these three factors. Whenever we are considering somebody's,
Dr. Asif Rahman: we need to
Dr. Asif Rahman: make them you volumeic. We need to normalize their heart rate, and then we need to work on their bas of constriction. Next
Dr. Asif Rahman: our treatment. We,
Dr. Asif Rahman: a Thai aside, diuretic to control volume calcium, channeled walkers and rass blockers
Dr. Asif Rahman: for systemic vascular resistance. Right? So this should be your initial combination of with with any. So you can use a thigh-side diuretic for the rice blocker.
Dr. Asif Rahman: You can use a long acting calcium channel blocker with a ras proper, or you can use the other way around, so these three, in any combination should be your initial choices
Dr. Asif Rahman: right
Dr. Asif Rahman: next.
Dr. Asif Rahman: Next
Dr. Asif Rahman: we can go forward. There you go. The next three choices are asosterone antagonists like spy, an electron beta blockers or direct base of dilators which are, and that is a separate talk about hydraulism and monoxidal. So I use hydraulicine,
Dr. Asif Rahman: my probable fifth or sixth, add on
Dr. Asif Rahman: after I've used up the fizzy and raspberries, and and the and Loda P. Norvass group of medications, next
Dr. Asif Rahman: and next.
Dr. Asif Rahman: And finally, we have the cloned deans and the alpha blockers and the nitrate. So that's how far? Because they are full of side effects and unacceptable side effects. So if we use the initial ones, the bio sides long acting, and the Ras poppers in the maximal doses,
Dr. Asif Rahman: and they have not been controlled. We now call them resistant hypertensives, and then we add on something next,
Dr. Asif Rahman: and we can go on.
Dr. Asif Rahman: Okay,
Dr. Asif Rahman: Seventy Two year old male is evaluated for difficult to control
high blood pressure, diabetes, Stage four ckd The
Dr. Asif Rahman: them creating has increased over the past three years consistent with Tkd. He's been on the same anti-hypoten, said Regiment
Dr. Asif Rahman: for for the three here's hydro floor thighs I my cinder pearl and loripine and mycopal all he had years for the medication regimen your emotional side effects. He's been. He's not been taking any over the counter and exercises
Dr. Asif Rahman: when examination, blood pressure is really high and not controlled, heart rate is controlled without orthostatic changes. There is no elevation of Jdp. Cardiac, Exam. Is normal, and there is a trace edema of the lower extremities, creating three point two Gfr. Twenty, four
Dr. Asif Rahman: urine alumin to create ratio is elevated at six hundred and fifty. What should we do?
Dr. Asif Rahman: Three seconds later? Next,
Dr. Asif Rahman: we control the volume. We control the volume, we control the heart rate. We control the systemic vascular resistance. We change the hydrolorphis. I to bring the volume down even more.
Dr. Asif Rahman: Next,
Dr. Asif Rahman: a couple of studies, and I've already alluded to them aces and arms.
Dr. Asif Rahman: We're good in the on-target study, but there was a higher incidence of Aki and Hyper Calamia should never, ever ever be given
Dr. Asif Rahman: right
Dr. Asif Rahman: Direct Drennan inhibitors was found to have an increased incidence of Cba in diabetics, and that's why it has lost its popularity. Right improved blood pressure control, as I said, was seen when an ace and an arm is added to a diuretic or
Dr. Asif Rahman: and mineral corticoid or aldosterone antagonist, right? So as parano Lectone, with a diuretic spern lactone with an as or an or right so definitely think about using that next
Dr. Asif Rahman: spend some time here, So control of blood pressure goal one hundred and thirty of over eighty, with the use of a raspberry pi, I must say
Dr. Asif Rahman: rash blockers is one hundred percent contraindicated, and anybody who's pregnant what is about, or thinking of becoming pregnant, so please never ever use that. It is also contradicated to anybody who has had a reaction with an enjoyedema, right
Dr. Asif Rahman: control of blood sugar with a hemoglobin, a one, C of less than seven percent. It used to be six and a half percent. It is now seven percent
Dr. Asif Rahman: Ldl goal of less than one hundred. And if you have documented God and doctrine disease less than seven D. Remember, we're trying to prevent the stopping of somebody's art, because even in chronic kidney disease, it is the heart which is the number one killer in these individuals price.
Dr. Asif Rahman: The drugs that we use exclusively is rass blockers. We've gone through them
Dr. Asif Rahman: maximally tolerated those never in combinational face, and an arm never in pregnancy or allergies. Right
Dr. Asif Rahman: here is a new one completely within the last twelve months. The new kid on the block is these Sglt, two blockers,
Dr. Asif Rahman: the Guardians, the far segas, the invokanas initially used for the treatment of diabetes. It is now used without any diabetes being present in the slowing of progression of renal disease. Right?
Dr. Asif Rahman: Do not start in Ckd four or greater. Be careful in obese individuals, and those prone to frequent uti's. You need to become familiar with the use, because they are some.
Dr. Asif Rahman: Be careful about willy-nilly handing it out
Dr. Asif Rahman: Candy, because I said so today. But once you become comfortable. Everybody should be on that
Dr. Asif Rahman: a low protein diet has been found to be helpful in slowing progression of Reno disease, and I've given you zero point six grams per kilo per day, and especially red meat, if you can avoid.
Dr. Asif Rahman: And and the quick thing is to say, make everybody a vegetarian. Right? Make everybody a vegetarian,
Dr. Asif Rahman: but sure how much? How much is zero point? Six grams per kilo. It should be.
Dr. Asif Rahman: The thickness of your palm the size of your farm in one day should be the allowable amount of meat protein that a patient should be taking, so that is usually good uric acid control controversial, whether it is helpful. But if
Dr. Asif Rahman: the level is high and patient is having gouty attacks,
Dr. Asif Rahman: absolutely bring those those levels down the
Dr. Asif Rahman: next.
Dr. Asif Rahman: This is
Dr. Asif Rahman: a slide that I've chosen just to make make you all away. These are people with stage three and four non diabetic kidney disease, and twenty four approaching excretion of less than one gram, one to three gram and over three grams, and and they control their blood pressures to one hundred and forty, over ninety, and one for
Dr. Asif Rahman: five, over seventy, five, and they've and they check how quickly their Gfrs decrease next
Dr. Asif Rahman: next
Dr. Asif Rahman: next. Okay. So in all situations, if you have prognoria and you don't control, if you do control. Their blood pressure is tighter to a goal of one hundred and twenty, five, over seventy five. Your loss in Gfr is slower.
Dr. Asif Rahman: So this is just another way of saying, for nurture is bad, especially in pro-newic patients. Please control their blood pressures as tightly as you can, as lower as you can go next.
Dr. Asif Rahman: A thirty-seven year, old man,
Dr. Asif Rahman: it comes presents with a demon. Blood pressure is high, bound to have a seat of creating into one over eight real vib. She shows vocal segment to doomeryl sclerosis.
Dr. Asif Rahman: It's a idiopathic to metal. The disease. He started on a license April loop diuretic a podium purosomy is added one week later, wonderful blood pressure protein has decreased from six grams to three grams. But asylum creatine has increased to three point two. What do we do
Dr. Asif Rahman: stop the A's switch to a Baylor barker, evaluate perennial octage to nosis, stop the loop, continue the current, anti have tensives and reach exceed them creates in one week. Stop the ace and switch to an arb. Start steroids, encyclopaedia to treat this nominal disease,
Dr. Asif Rahman: and next there you go So a rise and see them creating should not knee- yourwise make you stop the ace inhibitors.
Dr. Asif Rahman: You can calm down. Everything is getting better.
Dr. Asif Rahman: Blood Pressure is better for your years. Better. You're in the right track. So the only reason to stop an asylum better, or an arm is a consistent rise every time you check it. It is higher Now you've got a situation of a two kidney injury, but if it jumps up a little and stabilizes, you're good to go
Dr. Asif Rahman: next.
Dr. Asif Rahman: Managing complications. The full complications are anemia, iron deficiency, metabolic acidosis, and secondary hyperbolicism.
Dr. Asif Rahman: Next,
Dr. Asif Rahman: for anemia we give them what is called an a retrosite stimulating agent.
Dr. Asif Rahman: Next,
Dr. Asif Rahman: for iron deficiency. We give them Iv. Appeal iron. Next,
Dr. Asif Rahman: we give bicarbon in it. Next
Dr. Asif Rahman: we control their phosphorus, give them vitamin d, and we give them a drop of S in a calculation. We are getting really really specialized when we are coming to Santa Cruz. But you need to know about the complications, because many times. Even my residents say, Oh, yeah, even global is nine. It has been nine for the last five years. It's stable.
Dr. Asif Rahman: There is no such thing as stable. It is an abnormality which is in which, as a side effects of chronic kidney disease, and should be treated correctly, so that the patient feels better right.
Dr. Asif Rahman: Next
Dr. Asif Rahman: sixty five-year-old woman we are coming to the end sixty, five year old woman is being evaluated for long standing diet in their property and hypertension. You can see a medication. Blood pressure is one hundred and thirty. Eight of the seventy lungs are clear. The exam is unremarkable. Gfr. Is twenty, one
Dr. Asif Rahman: which of the following is the most appropriate next step in the management of this patience of India. The
Dr. Asif Rahman: right discontinue, like Cinderella, initiate Esa's measure, ceta methrosite measure iron stores
Dr. Asif Rahman: next
Dr. Asif Rahman: iron stores
Dr. Asif Rahman: next.
Dr. Asif Rahman: So iron goals are how you got to get the transparent saturation line saturation over twenty percent and fetish them over one hundred next.
Dr. Asif Rahman: This person's
Dr. Asif Rahman: transparent saturation. It's thirty, two, thirty, three, and hemoglobin is eight point nine; next.
Dr. Asif Rahman: What do we give? We give them some it through point, and here is next box tells us
Dr. Asif Rahman: so. When do you give somebody appropriate, or that it's important? Hemoglobin needs to be less than ten C Kd. Speed stages, three, four, five normal iron stores. Love work has to be done within forty eight hours prior to each dose
Dr. Asif Rahman: It'sropolitan should be held with hemoglobin reaches above eleven, otherwise Medicare will not reimburse you. There should be no active cancer, and their blood pressure should be controlled. Those are the restrictions of giving Ep. Of people what is holy for next?
Dr. Asif Rahman: Ah, this is a slide showing us the bicarbonate of seventeen. And what do we want to do to this person.
Dr. Asif Rahman: Next
Dr. Asif Rahman: sodium, bicarbonate therapy, which has been shown to slow the the
Dr. Asif Rahman: the progression of renewal disease. Next the
Dr. Asif Rahman: bring level to twenty to twenty six, and this this is an easy one, right so, and and how much to give we don't know. You just start somewhere with slogan by carbon, it by pills, and you maintain the seed and by carbonate level
Dr. Asif Rahman: next.
Dr. Asif Rahman: Okay. So I have highlighted a low vitamin d level, a high Pta level, a normal phosphorus level and a low calcium level. Right? And what do we do with this person?
Dr. Asif Rahman: Hit the button?
Dr. Asif Rahman: Begin some vitamin, d
Dr. Asif Rahman: normalize their vitamin d, which will help their calcium, which will help their P. Th: So it's very important to check and normalize vitamin d levels. Next.
Dr. Asif Rahman: Okay, we have low calcium, correct, low vitamin d replace high phosphorus, give binders and high pta specialized therapy.
Dr. Asif Rahman: Next.
Dr. Asif Rahman: So summary is control, blood pressure. Use a ras blocker for Gloria needs to be decreased diabetes, acidosis, protein restriction.
Dr. Asif Rahman: Next
Dr. Asif Rahman: identify patients with chronic kidney disease. Determine cause. If you feel that there is something reversible manage complications, slow the progression of bele disease, prepare for dialysis and or transplantation, and refer to a nephrologist when you think appropriate, and we think that
Dr. Asif Rahman: any time you are uncomfortable
Dr. Asif Rahman: talking about chronic kidney disease is a time for referral, or at least to referral in States three B or greater. So something A. G. Of R. Less than forty five next.
Dr. Asif Rahman: I made it by
Dr. Asif Rahman: one hundred and fifty-five.
Quality Insights: Thank you so much, Dr. Ram, and this has been an excellent presentation. I apologize. So much for the technical problems that we had at the beginning, because we only have about four minutes left in the hour.
Quality Insights: Um, which means that we don't really have a lot of time for questions, but I will say that if anyone does have a question, go ahead and enter that into ear. The chat or the Q. And A. Box at this time, and if you do come up with some questions, and we don't have time for that um kristy, or I can reach out and and work with Dr. Ram and I'm getting
Dr. Asif Rahman: Yeah.
Quality Insights: Yeah. So again, Thank you so much, Kristy: i'll kind of turn things over to you to. Ah, close us up and and see if there's any kind of closing remarks that you would like to make.
Kristi Krug: I just want to say thank you to Dr. Raman. It was an excellent presentation, and thank you all for joining us today, and we will have a recording of this available. Is that correct?
Quality Insights: Yes, yes, a recording of this will be available and posted on our website, and I will be sure to let everyone, not only the people that have attended, but those that registered, and maybe either couldn't get on or weren't able to attend, they'll get that information as well.
Kristi Krug: Excellent!
Kristi Krug: Thank you for i'm here.
Quality Insights: Thank you all so much. Have a great afternoon, everyone.
Kristi Krug: Thanks everybody. Bye, bye,