#64 – KDIGO Guidelines

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What are KDIGO and KDOQI???

  • The 2 Organizations
    • Kidney Disease Outcomes Quality Initiative (KDOQI)
      • US Based
      • Developed in 1997 by National Kidney Foundation
    • Kidney Disease: Improving Global Outcomes (KDIGO)
      • Global organization developing and implementing evidence based clinical practice guidelines in kidney diseases
      • Developed in 2003 by NKF
    • Essentially individual entities, but both comment various aspects of kidney diseases
  • 2012 Guidelines
    • Published by KDIGO and commented by KDOQI
    • 5 chapters

Chapter 1: Definition and Classification of CKD

  • Definition
    • Abnormalities in kidney structure or function, present for > 3 months, with implications on health
  • Staging
    • Based on causes, GFR category, and albuminuria category
  • Predicting Prognosis of CKD
  • Evaluation of GFR
    • Recommend using serum creatinine and GFR estimating equation for initial assessment
    • Recommend only using cystatin C in adult patients with decreased GFR but without markers of kidney damage if diagnosis of CKD is required
  • Evaluation of Albuminuria
    • Initial testing for proteinuria should be an early morning urine sample(in descending order of preference):
      • Urine albumin-to-creatinine ratio (ACR)
      • Urine protein-to-creatinine ratio (PCR)
      • Reagent strip urinalysis for total protein with automated reading
      • Reagent strip urinalysis for total protein with manual reading
    • Microalbuminuria should no longer be used by laboratories
    • If ACR > 30mg/g, then proceed to confirm with a random untimed urine sample

Chapter 2: Definition, Identification, and Predication of CKD Progression

  • Assess albuminuria at least annually
  • CKD progression is based on the one of the following:
    • Decline in GFR category
    • Drop in eGFR by ≥ 25% of baseline
    • Sustained decline in eGFR by > 5mL/min/year
  • Identify known risk factors associated with CKD progression
    • Cause of CKD
    • Age
    • Gender
    • Hypertension
    • Hyperglycemia
    • Dyslipidemia
    • Smoking
    • Obesity
    • History of CVD
    • Ongoing exposure to nephrotoxic agents

Chapter 3: Management of Progression and Complication of CKD

  • Hypertension
    • BP ≤ 140/90 if urine albumin excretion < 30mg/d
    • BP ≤ 130/80 if urine albumin excretion > 30mg/d
    • Recommend ACEI or ARB
  • Protein Intake
    • Recommend protein intake 0.8g/kg/d
  • Glycemic Control
    • Recommend HbA1C AROUND 7.0%
    • ***newer ACE guidelines recommend < 6.5% with SGLT2i**
  • Recommend < 2g/day
    • Lifestyle
      • Recommend 30 min/day five times per week, smoking cessation, and healthy weight (BMI 20-25)
  • Complications Associated with CKD
    • Anemia
      • Diagnosed at < 13g/dL in men and < 12 g/dL in women
      • Screening in patients with CKD:
        • Stage G1-2 – when clinically indicated
        • Stage 3a-3b – at least annually
        • Stage 4-5 – at least twice per year
    • Metabolic Bone Disease
      • Obtained baseline calcium, phosphate, PTH, and ALP at least once in patients with GFR < 45 mL/min
      • Not recommended to screen with bone mineral density testing
      • Not recommended to supplement vitamin D of bisphophonates with deficiency or strong clinical rationale
    • Acidosis
      • Supplement oral bicarbonate in patients with serum bicarbonate < 22 mmol/L

Chapter 4: Other Complications of CKD

  • CVD
    • All CKD patients are at increased risk for CVD
    • Recommend same testing and treating as non-CKD patients
    • Use caution when interpreting NT-proBNP and troponins
  • PVD
    • Recommend regular podiatric assessment
  • Medication Management
    • Recommend using GFR for dosing adjustments
      • Example – Metformin
        • Stage G1-3a – continue
        • Stage G3b – monitored
        • Stage G4-5 – discontinued
  • Imaging studies and radiocontrast
    • Avoid if possible, but do not hold if needed
    • Following KDIGO Clinical Practice Guidelines for AKI
      • Avoid high osmolar agents
      • Use lowest contrast dose possible
      • Stop nephrotoxic agents before and after
      • Maintain adequate hydration
      • Measure GFR 48-96 hours after

Chapter 5: Referral to Specialist and Models of Care

Cottage Physician (1893)

References

  1. KDIGO. Clinical Practice Guideline for the Evaluation and Management of CKD. 2012.
  2. Inker LA, Astor BC, Fox CH, et al. KDOQI US commentary on the 2012 KDIGO clinical practice guideline for the evaluation and management of CKD. Am J Kidney Dis. 2014; 63(5):713-35. [pubmed]
  3. Stevens PE, Levin A. Evaluation and management of chronic kidney disease: synopsis of the kidney disease: improving global outcomes 2012 clinical practice guideline. Ann Intern Med. 2013; 158(11):825-30. [pubmed]
  4. Andrassy KM. Comments on ‘KDIGO 2012 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease’. Kidney Int. 2013; 84(3):622-3. [pubmed]

PAINE #PANCE Pearl – Genitourinary

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Question

This one is a quick one this week. When evaluating a patient with testicular pain (either acute or chronic), what are the specific physical examination techniques you can perform and what conditions do they help rule in/out?

Answer

  1. Position of the Testicle
    • Side-lying (long axis transverse) position suggests testicular torsion
      • also called the “Bell Clapper” deformity
  2. Cremesteric Reflex
    • Pinching the skin of the upper thigh causes elevation of testes
      • If absent, suggests testicular torsion
  3. Blue Dot Sign
    • Tender nodule with blue discoloration on the upper pole of the testes
      • If present, suggests appendix testes torsion
  4. Prehn Sign
    • Manual elevation of testes relieves the pain
      • If positive, suggests epididymitis
  5. Transillumination
    • In evaluating scrotal swelling, ability to transilluminate the scrotum suggests hydrocele.
    • If unable to transilluminate, suggests varicocele or mass

Ep-PAINE-nym

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Sertoli Cells

Other Known Aliases – none

Definition – sustentacular cell of the convoluted seminiferous tubule of the testes

Clinical Significance – these cells are activated by FSH to produce and mature sperm during spermatogenesis

History – Named after Enrico Sertoli (1842-1910), who was an Italian physiologist and histologist and received his medical doctorate from the University of Pavia in 1865. His love and passion for histology was groomed while training under Eusebio Oehl, who was an early pioneer in microscopic anatomy and histopathology. He would go on to become professor of anatomy and physiology at the Royal School of veterinary medicine in Milan and it was here that he founded the laboratory of experimental physiology. In 1865, during his tenure in Milan, he published the paper describing his eponymous cell.

References

  1. Firkin BG and Whitwirth JA.  Dictionary of Medical Eponyms. 2nd ed.  New York, NY; Parthenon Publishing Group. 1996.
  2. Bartolucci S, Forbis P.  Stedman’s Medical Eponyms.  2nd ed.  Baltimore, MD; LWW.  2005.
  3. Yee AJ, Pfiffner P. (2012).  Medical Eponyms (Version 1.4.2) [Mobile Application Software].  Retrieved http://itunes.apple.com.
  4. Whonamedit – dictionary of medical eponyms. http://www.whonamedit.com
  5. Up To Date. www.uptodate.com
  6. Sertoli E. Dell’esistenza di particolari cellule ramificate nei canalicoli seminiferi del testicolo umano. Morgagni, 1865; 7: 31-40

Ep-PAINE-nym

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Fournier’s Gangrene

Other Known Aliases – none

Definition – necrotizing fasciitis of the external genitalia and/or perineum

Clinical Significance – this infection commonly affects older men and is associated with diabetes mellitus or a compromised immune system. Other risk factors include trauma or surgery to the perineal area, alcoholism, and childbirth. Pain, erythema, crepitus, and fever are common findings and treatment is aggressive surgical debridement and antibiotics to cover anaerobic and facultative pathogens.

History – Named after Jean Alfred Fournier (1832-1914), who was a French dermatologist and venereologist, and received his medical doctorate in 1860 while studying in Paris. He would begin his career as an understudy of Philippe Ricord at the Hôpital du Midi and would later become médecine des hôpitaux at the famed Hôtel-Dieu de Paris. It was in 1883 when he presented a case series of patients with gangrene of perineum and for which this eponym is attributed, although it was first described and published in 1764 by Baurienne. He is best known for his work with congenital syphilis (for which he has two additional eponyms) and advancing the study of venereal diseases and their connection to degenerative diseases.

References

  1. Firkin BG and Whitwirth JA.  Dictionary of Medical Eponyms. 2nd ed.  New York, NY; Parthenon Publishing Group. 1996.
  2. Bartolucci S, Forbis P.  Stedman’s Medical Eponyms.  2nd ed.  Baltimore, MD; LWW.  2005.
  3. Yee AJ, Pfiffner P. (2012).  Medical Eponyms (Version 1.4.2) [Mobile Application Software].  Retrieved http://itunes.apple.com.
  4. Whonamedit – dictionary of medical eponyms. http://www.whonamedit.com
  5. Up To Date. www.uptodate.com
  6. Fournier, J.A. Gangrène foudroyante de la verge. La Semaine Médicale. 3 1883;(56): 345–347
  7. Toodayan N. Jean Alfred Fournier (1832-1914): His contributions to dermatology. http://www.odermatol.com/issue-in-html/2015-4-32/
  8. Waugh MA. Alfred Fournier, 1832-1914. His influence on venereology. Br J Vener Dis. 1974; 50(3):232-6. [PDF]

PAINE #PANCE Pearl – Rheumatology

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Question

49yo woman, with a history of hypertension and GERD, presents to your clinic with a six month history of bilateral shoulder weakness that she first noticed when putting on sweaters and jackets and carrying in groceries. She denies any history of pain, repetitive trauma, or weakness in the hands. On physical examination, she has 3.5/5 strength in shoulder abduction and flexion, as well as the below rash. She reports the rash has been present for about the same time, but doesn’t really bother her.

  1. What lab is likely to be profoundly elevated and what lab is most specific to this condition?
  2. What is the most likely diagnosis?

Answer

  1. Due to the inflammatory myopathy, muscle enzymes are often extremely elevated and are helpful in initial screening. Creatine kinase (CK) is most commonly ordered, but lactate dehydrogenase (LDH), aspartate aminotransferase (AST), and alanine aminotransferase (ALT) are often elevated as well. The most common myositis-specific autoantibody is Anti-Jo 1 with others being Anti-SRP and Anti-MI-2.
  2. Given this history and dermatologic “shawl sign”, dermatomyositis is most likely. Polymyositis does not present with skin findings.

Ep-PAINE-nym

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Kienböck Disease

Other Known Aliases – none

Definition – avascular necrosis of the lunate

Clinical Significance – most often results from trauma with biomechanical and vascular abnormalities that lead to progressive bone death. Patients will report wrist pain with decreased range of motion and grip strength. MRI is best for early diagnosis and treatment depends on the stage of disease using the Lichtman Classification system.

History – Named after Robert Kienböck (1871-1953), who was an Austrian radiologist and received his medical doctorate from the University of Vienna in 1895. He would explore the new and blossoming field of radiology before becoming the head of the radiological department at Vienna General Hospital before becoming professor of radiology in 1926. He was a pioneer in the use of x-rays for medical diagnosis and would co-found the Vienna Radiology Society in 1923. He would publish his eponymous condition in 1910 in his treatise Über traumatische Malazie des Mondbeins und ihre Folgezustände (Traumatic malacia of the lunate and its consequences).

References

  1. Firkin BG and Whitwirth JA.  Dictionary of Medical Eponyms. 2nd ed.  New York, NY; Parthenon Publishing Group. 1996.
  2. Bartolucci S, Forbis P.  Stedman’s Medical Eponyms.  2nd ed.  Baltimore, MD; LWW.  2005.
  3. Yee AJ, Pfiffner P. (2012).  Medical Eponyms (Version 1.4.2) [Mobile Application Software].  Retrieved http://itunes.apple.com.
  4. Whonamedit – dictionary of medical eponyms. http://www.whonamedit.com
  5. Up To Date. www.uptodate.com
  6. Orthobullets. Kienbock Disease. https://www.orthobullets.com/hand/6050/kienbocks-disease
  7. Wagner JP, Chung KC. A Historical Report on Robert Kienböck and Kienböck Disease. The Journal of Hand Surgery. 2005;30(6):1117-1121. [link]
  8. Kienböck R. Über traumatische Malazie des Mondbeins und ihre Folgezustände: Entartungsformen und Kompressionfrakturen. Fortschritte auf dem Gebiete der Röntgenstrahlen. 1910–1911; 16: 77-103.

#63 – Osteoarthritis Treatment

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Quick Osteoathritis Review

  • Signs and Symptoms
    • Progressive joint pain
      • Stage 1 – Intermittent, Predictable, limits only high-impact activities
      • Stage 2 – Constant, effects daily activities
      • Stage 3 – Constant with intermittent, unpredictable, intense pain with severe limitations
    • Worse in the afternoon
    • Decreased ROM
    • Joint-line tenderness
    • Swelling and effusions
  • Radiography
    • 4 Radiographic Criteria of Osteoarthritis
      • Diminished joint space
      • Bony sclerosis
      • Osteophytes
      • Subchondral cyst

General Osteoarthritis Treatment Principles

  • Education
    • Discuss modifiable risk factors
    • Prognosis
    • Treatment options and timeline
  • Goal Setting
    • Identify current issues
    • Set priorities
    • Develop realistic plan
      • Multiple short term goals to achieve long term goal
      • Directed at minimizing pain, optimizing function, and modify joint damage
  • Clinical Assessment and Follow-up
    • Should be every 3 months by provide
    • Factors to be addressed and discussed during visits:
      • Impact of pain on daily living and quality of life
      • Functional limitations
      • Recreational and/or occupational aspirations
      • Sleep disturbances
      • Fall risk assessment
      • Expectations of treatment

Updated Guidelines from ACR/AAF

2019 updated guidelines from American College of Rheumatology and American Arthritis Foundation

Non-Pharmacologic Treatment

  • Should be first line either alone or with pharmacologic therapy
  • Physical therapy is the mainstay of non-pharmacologic treatment
    • Usually 6 weeks
  • Weight loss
    • Loss of 10% of body weight equals 50% reduction in pain scores
    • Adipokines (leptin and adiponectin) released by adipose tissue are known inflammatory factors
    • Consultation with dietician can be helpful
  • Exercise
    • Exercising have comparable effects on pain and function compared to NSAIDs
    • Low-impact is best, but tailor to patient’s function and limitations
    • Activities to help with core strength and balance can have significant reductions in falls
  • Braces and Splints
    • When possible, these aids can have significant benefit in pain reduction during activities

Pharmacologic Treatments

  • Topical NSAIDs should be considered prior to oral NSAIDs
    • Knee > hand efficacy
    • Diclofenac 1% gel – 4g (large joints) or 2g (small joints) applied 3-4x/day
      • Now available OTC
  • Oral NSAIDs > acetaminophen
    • COX-2 selective NSAID
      • Celecoxib 100-200mg daily or BID
      • Diclofenac 75mg BID
      • Meloxicam 10-15mg daily
  • Duloxetine can be helpful
    • Desensitizes central nociceptive pain processing
    • 60-120mg daily
  • Intrarticular glucocorticoid injections have limited role
    • Can be used for short-term relief
      • Most helpful with the hip
      • Long-term use can damage cartilage
    • Triamcinolone 40mg
  • Hyaluronic acid is controversial with limited data
  • Avoid recommended glucosamine, chondroitin, vitamin D, and fish oil due to lack of clear data showing benefit

Surgical Indications and Management

Cottage Physician (1893)

References

  1. Hawker GA, Stewart L, French MR, et al. Understanding the pain experience in hip and knee osteoarthritis–an OARSI/OMERACT initiative. Osteoarthritis Cartilage. 2008; 16(4):415-22. [pubmed]
  2. French SD, Bennell KL, Nichols PJ, Hodges PW, Dobson FL, Hinman RS.  What do people with knee or hip osteoarthritis need to know? An international consensus of essential statements for osteoarthritis.  Arthritis Care Res (Hoboken). 2015;57(6):809. [pubmed]
  3. Bodenheimer T, Lorig K, Holman H, Grumbach K. Patient self-management of chronic disease in primary care. JAMA. 2002; 288(19):2469-75. [pubmed]
  4. Messier SP, Mihalko SL, Legault C, et al. Effects of intensive diet and exercise on knee joint loads, inflammation, and clinical outcomes among overweight and obese adults with knee osteoarthritis: the IDEA randomized clinical trial. JAMA. 2013; 310(12):1263-73. [PDF]
  5. Zhang W, Nuki G, Moskowitz RW, et al. OARSI recommendations for the management of hip and knee osteoarthritis: part III: Changes in evidence following systematic cumulative update of research published through January 2009. Osteoarthritis Cartilage. 2010; 18(4):476-99. [pubmed]
  6. 2019 American College of Rheumatology/Arthritis Foundation Guideline for Management of Osteoarthritis of the Hand, Hip, and Knee.  Arthritis Care Res (Hoboken). 2020;72(2):149-162. [pubmed]

PAINE #PANCE Pearl – Rheumatology

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Question

43yo woman, with a history of hypertension and GERD, presents to your clinic with a six month history of bilateral shoulder weakness that she first noticed when putting on sweaters and jackets and carrying in groceries. She denies any history of pain, repetitive trauma, or weakness in the hands. On physical examination, she has 3.5/5 strength in shoulder abduction and flexion, as well as the below rash. She reports the rash has been present for about the same time, but doesn’t really bother her.

  1. What lab is likely to be profoundly elevated and what lab is most specific to this condition?
  2. What is the most likely diagnosis?

Ep-PAINE-nym

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Monteggia Fracture

Other Known Aliases – none

Definition – proximal 1/3 ulnar fracture with radial head dislocation

Clinical Significance – This type of injury pattern is most commonly seen with FOOSH injuries and is more common in children than adults with a peak incidence of 4-10 years of age. There are four different classifications depending on the injury pattern. There is also high incidence of neurovascular compromise and a good bedside exam is paramount prior to surgical repair.

History – Named after Giovanni Battista Monteggia (1762-1815), who was an Italian surgeon and received his medical doctorate from the University of Pavia in 1789 at the age of seventeen. He would begin his career as a surgery apprentice at the Great Hospital in Milano in 1790 culminating in professor of anatomy and surgery in 1795. His knowledge of anatomy and skill as a surgeon impressed his a very famous colleague at the University of Pavia, one Antonio Scarpa. He published his eponymous injury in 1814 in his textbook entitled “Institziono Chirurgiche”. Of note, the first radiograph was not taken until 1895.

References

  1. Firkin BG and Whitwirth JA.  Dictionary of Medical Eponyms. 2nd ed.  New York, NY; Parthenon Publishing Group. 1996.
  2. Bartolucci S, Forbis P.  Stedman’s Medical Eponyms.  2nd ed.  Baltimore, MD; LWW.  2005.
  3. Yee AJ, Pfiffner P. (2012).  Medical Eponyms (Version 1.4.2) [Mobile Application Software].  Retrieved http://itunes.apple.com.
  4. Whonamedit – dictionary of medical eponyms. http://www.whonamedit.com
  5. Up To Date. www.uptodate.com
  6. Orthobullets. Monteggia Fractures. https://www.orthobullets.com/trauma/1024/monteggia-fractures
  7. Monteggia GB. Instituzioni Chirurgiches. Vol. 5. Maspero; Milan, Italy: 1814.