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NEPHROLOGY:

Alive and WellCLAIRE KASSAKIAN, MD

NORTHWEST RENAL CLINIC

Dialysis

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overview

� SGLT2 Inhibitors and GLP-1 Receptor Agonists:

Changing Diabetes Management with CKD

� ACEi/ARB Warnings: Keeping It Straight

� AHA Hypertension Guidelines: No more JNC 8

� Anticoagulation in CKD: DOACs

� The future of hyperkalemia: Beyond Kayexalate

� When to Refer to Nephrology

� Questions

Your question is our question

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overview� SGLT2 Inhibitors and GLP-1 Receptor Agonists:

Changing Diabetes Management with CKD

The History of Management

SGLT2 Inhibitors andGLP-1 Receptor Agonists:

Giving CREDENCE to Changes inDiabetes Management and CKD

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SGLT2 Inhibitors:

SGLT2 Inhibitors:

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SGLT2 Inhibitors:

SGLT2 Inhibitors:

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SGLT2 Inhibitors:

CREDENCE TRIALCanagliflozin and Renal Events in Diabetes

and Nephropathy Clinical Evaluation

� Leading the way: CANVAS Trial (2017)

� CREDENCE OUTCOMES:

� Reductions noted in:

� Doubling of creatinine (21 vs 34/1000 P-Y)

� Progression to ESRD (20.4 vs 30/1000 P-Y)

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SGLT2 Inhibitors:

� CREDENCE TRIAL� Canagliflozin

� DECLARE� Dapagliflozin

� EMPA-REG OUTCOM

� Empagliflozin

Trouble with

the FLOZINS… � 1) Increased genital and

urinary tract infections

including mycotic infections

� 2) Necrotizing fasciitis of the

perineum (Fournier’s gangrene)

� 3) Pancreatic Cancer

� 4) 1 and 2

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Trouble with

the FLOZINS…

The results are mixed:

2016 CANVAS TRIAL

OBSERVE-4D

JOHNS HOPKINS

GLP-1 Receptor Agonists

Glucagon-like Peptide Agonists

� ELIXA TRIAL

� LEADER TRIAL (Liraglutide)

� Significant reduction in:

� CV mortality

� Nonfatal MI

� Nonfatal stroke

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GLP-1 Receptor Agonists

Mechanism Of Action

GLP-1 Receptor Agonists

Mechanism Of Action

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GLP-1 Receptor Agonists

Glucagon-like Peptide Agonists

� ELIXA TRIAL

� LEADER TRIAL

� Liraglutide

� REWIND Trial

� AWARD 7 Trial

Trouble with

the GLP1

Agonists is…� 1) Pancreatic Cancer

� 2) Hepatocellular Carcinoma

� 3) Renal Cell Carcinoma

� 4) None of the Above

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Diabetic

Nephropathy:

Hyperfiltration

and

Proteinuria

Hyperfiltration

Studies for ACEi and ARBs

Why No ACEi + ARB

Hyperfiltration

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The Basics of

Diabetic

Nephropathy:

PROTEINURIA

Hyperfiltration

Studies for ACEi and ARBs

Why No ACEi + ARB

� Names of Key Trials

Proteinuria on the Glomerular Level

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Key Trials in Diabetic

Nephropathy

� RENAAL Trial

� Irbesartan Diabetic Nephropathy Trial (IDNT)

� ONTARGET

� ALTITUDE (Aliskiren + ACE or ARB)

overview � ACEi/ARB Warnings: Keeping It Straight

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ACEi/ARB Warnings: Keeping It Straight

When To Stop

the ACEi/ARB

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overview� AHA Hypertension Guidelines: No more

JNC 8

Hypertension Now

JNC 8

� <140/90 All groups aside from patients

over the age of 80.

NEW AHA Guidelines

� Normal: <120/80mmHg

� Elevated: Systolic 120-129 and

diastolic <80

� Stage 1: Systolic 130-139 or diastolic

80-89

� Stage 2: Systolic 130-139 or diastolic at

least 90mmHg

� Guide eliminates category of

prehypertension

� http://www.acc.org/latest-in-cardiology/articles/2017/11/08/11/47/mon-5pm-bp-guideline-aha-2017

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All direct oral anticoagulants are metabolized in some capacity by what organ?

� 1) The KIDNEYS

� 2) The brain

� 3) The lungs

� 4) None of the above

Anticoagulation in CKD and ESRD: DOACs

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Major trials in DOACs

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RE-LY DABIGATRON

ROCKET RIVAROXABAN

ARISTOTLE Apixaban

ENGAGE Edoxaban

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overview� The future of hyperkalemia: Beyond

Kayexalate

� When to Refer to Nephrology

Safe Horizons for Hyperkalemia

� Dangers of KAYEXALATE (Sodium Polystyrene Sulfonate)

� August 2019

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What’s New?

� PATIROMER (Veltassa, Relypsa)

� ZIRCONIUM CYCLOSILICATE (Lokelma)

When Does Your

Patient Need a

Nephrologist ?

CKD

ESRD

Hyponatremia

Hypertension

Proteinuria

Hematuria

Edema

Hyperkalemia

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PRIMARY

MEMBRANOUS

NEPHROPATHY

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Thank you.

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QUESTIONS

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