Run the List Podcast Episode Summary

Episode Title: CKD: General Management
Date: April 28, 2025
Host: Walker Redd
Guest: Dr. Ryan Bonner, Assistant Professor of Medicine, Division of Nephrology and Hypertension, UNC
Podcast Theme: High-yield internal medicine education for trainees and practitioners

Episode Overview

This episode dives into the general management of Chronic Kidney Disease (CKD), aiming to provide listeners with a structured approach to evaluating, risk-stratifying, and managing patients with CKD, especially in outpatient settings. Host Walker Redd and nephrologist Dr. Ryan Bonner discuss best practices, important clinical pearls, pitfalls, and the impact of recent advances in pharmacologic options and team-based care.

Key Discussion Points and Insights

1. Assessing Kidney Function

• Common Tools: Kidney function is typically gauged by estimating the glomerular filtration rate (eGFR) using serum creatinine.
• Limitations: eGFR is less reliable in patients with extreme muscle mass, sarcopenia, or those taking certain medications (e.g., trimethoprim, new chemotherapeutics, some antiretrovirals).
• Alternative Biomarker: Cystatin C is a valuable additional marker, especially combined with creatinine, to better assess kidney function in patients where creatinine may misrepresent renal status.

“...the CKD EPI 2021 equation that doesn't include a race coefficient... is suitable for most folks, but it's less reliable at the extremes of muscle mass, which aren't uncommon.”
— Dr. Ryan Bonner [01:55]

• Clinical Pearl: For patients with unusual muscle mass or those on drugs affecting creatinine secretion: use both Creatinine and Cystatin C to estimate renal function.

2. Risk Stratification and Progression

• Beyond the Snapshot: CKD management isn’t just about the current eGFR—risk of progression guides long-term management decisions.
• KFRE (Kidney Failure Risk Equation): A validated, accessible tool combining age, sex, eGFR, and urine albumin-to-creatinine ratio to predict progression to kidney failure over 2–5 years.

“...not everybody with a creatinine of 1.5, for example, is at the same risk of progression... you can have a patient with a creatinine of 2 be at lower risk... compared to someone who has a creatinine of 1.5, but has four times the albuminuria.”
— Dr. Ryan Bonner [04:17]

• Albuminuria’s Role: Urine albumin-to-creatinine ratio (UACR) is critical for prognosis and management, influencing referrals and intensity of follow-up.

3. Medication Management & Preventing Progression

• Evidence-Based Therapies: Prioritize ACE inhibitors (ACEi), angiotensin receptor blockers (ARBs), SGLT2 inhibitors, GLP-1 receptor agonists, and non-steroidal MRAs.
• Focus on Adherence: Keep patients on proven therapies as much as possible, working with pharmacists to manage side effects, polypharmacy, and financial/access barriers.

“We need to make sure we keep patients on them... we really need to be familiar with these meds, how we can address the side effect profile... polypharmacy...”
— Dr. Ryan Bonner [07:23]

• Recent Evidence: Continuing ACEi/ARBs as CKD progresses slows further progression (referencing the STOP-ACE trial).

• Team Approach: Collaborate with pharmacists, dietitians, and case management to overcome complexity and fragmentation of care.

4. Managing Hyperkalemia in CKD

• Risk of Hyperkalemia: Use of ACEi, ARBs, MRAs increases with advancing CKD.
• Preventive Strategies: Optimize diuretic therapy (thiazide, loop), dietitian consultation for potassium intake, and consider potassium binders (e.g., sodium zirconium cyclosilicate) when needed.

“Initially, I tend to really make sure these patients are on adequate diuretic therapy... collaboration with our dietitian colleagues... potassium binders that are pretty effective.”
— Dr. Ryan Bonner [10:26]

5. Medication Pitfalls in CKD

• Medications to Avoid or Dose Carefully:
  • NSAIDs: Avoid due to risk of worsening renal function, hyperkalemia, salt retention, diuretic resistance.
  • Certain Antibiotics: Trimethoprim-sulfamethoxazole can cause severe hyperkalemia in those on RAAS blockers.
  • Analgesics/Sedatives: Tramadol, morphine, gabapentin (dose adjust), and especially baclofen, which can cause toxicity even at standard doses in renal dysfunction.

“Baclofen is really quite challenging and can be really, really unsafe, especially in advanced kidney disease. That’s even at therapeutic doses.”
— Dr. Ryan Bonner [13:56]

6. Clinical Pearls and Takeaways

• Thoroughly characterize CKD: Use both kidney function and albuminuria to risk-stratify.
• Start and maintain patients on evidence-based therapies; focus on continuity and addressing barriers to continued use.
• Dose medications appropriately: Closely monitor for side effects unique or exaggerated in CKD.

“...always making sure that you’re dosing that medication appropriately and keeping a close eye out for side effects that may not present themselves in someone who has normal kidney function.”
— Dr. Ryan Bonner [15:43]

Notable Quotes & Memorable Moments

• On holistic risk assessment:
  “Evaluation and management of chronic kidney disease isn’t just about how things are right now. Right. It’s not just about what the EGFR is at this moment. It’s about the risk of progression because that helps guide a variety of different elements of that management.”
  — Dr. Ryan Bonner [04:17]

• On NSAIDs in CKD:
  “The main concern with NSAIDs from my standpoint, is that it does impair your kidney’s ability to autoregulate its perfusion. So patients who are taking a lot of NSAIDS around the clock and become volume depleted can’t necessarily adjust in the same way and are at more risk of injury from that same insult...”
  — Dr. Ryan Bonner [12:55]

• On the team approach to CKD management:
  “I certainly can’t say enough about the importance and value of collaborating and having team based care with the clinical pharmacist, if that is support that is available. That I think has really, really improved the care that I provide and that is delivered to the patients...”
  — Dr. Ryan Bonner [07:23]

Timestamps for Key Segments

• Assessing Renal Function & Limitations: [01:55]
• Cystatin C & Extremes of Muscle Mass: [02:50]
• Risk Stratification using KFRE: [04:17]
• Albuminuria’s importance & referral decisions: [06:17]
• Team-Based Medication Management: [07:23]
• Managing Hyperkalemia: [10:26]
• Medications to Avoid/Dose (NSAIDs, Antibiotics, Baclofen): [12:47]
• Summary Pearls: [15:43]

Summary Table: Key Do’s and Don’ts

| Clinical Issue | Key Do’s | Key Don’ts | |-------------------------|--------------------------------------------------------|----------------------------------------------------| | Kidney Function | Use both Creatinine & Cystatin C as needed | Rely solely on creatinine in patients with extremes| | Progression Risk | Use UACR + eGFR + KFRE | Ignore albuminuria in risk assessment | | Therapy | Initiate/maintain ACEi, ARB, SGLT2i, GLP-1RA, etc. | Stop ACEi/ARB in CKD without good reason | | Hyperkalemia | Use diuretics, diet change, potassium binders | Discontinue RAAS blockers reflexively | | Drug Safety | Dose renally, avoid NSAIDs, baclofen, trim-sulfa | Prescribe contraindicated meds or ignore dosing |

Final Takeaways

• Get a comprehensive picture of CKD by combining eGFR, urine ACR, and patient-specific factors.
• Use risk calculators (KFRE) to individualize patient management and referrals.
• Keep patients on proven CKD therapies when possible—work through barriers as a care team.
• Know and avoid common medication pitfalls in CKD.
• Dose appropriately and always monitor for unique side effects in CKD.

Next episode: CKD Part 2 (Stay tuned to further your knowledge!)