Defining CKD and Risk Factors<br />
Objectives<br />Understand the definition of CKD<br />Describe risk factors for CKD<br />Become familiar with estimated GF...
Impact of Kidney Disease in NC<br />1 million living with CKD in NC<br />11,000 people currently on dialysis in NC<br />NC...
Background<br />NKF = National Kidney Foundation<br />1995 developed clinical practice guidelines for dialysis patients <b...
Background<br />Fall 1999, NKF approved proposal to move the clinical practice guideline initiative into a new phase<br />...
Ann Intern Med 2003; 139:137-47<br />http://www.annals.org/cgi/reprint/139/2/137.pdf<br />Am Fam Physician 2004; 70:869-76...
NKF K/DOQI Definition of Chronic Kidney Disease<br />Structural or functional abnormalities of the kidneys for &gt;3 month...
Is the Kidney Failure Acute or Chronic?<br />Acute<br />Chronic<br />Hx normal kidney function<br />Normal sized kidneys	<...
Assessing CKD risk<br />All individuals should be assessed to determine if they are at increased risk of developing CKD<br...
Types and Examples of Risk Factors for CKD<br />Am J of Kidney Diseases 39(2)Suppl 1, 2002:ppS7-S10<br />
Potential Risk Factors for Susceptibility to and Initation of CKD<br />
Relationship between the type of kidney disease and risk factors<br />Am J of Kidney Diseases 39(2)Suppl 1, 2002:ppS7-S10<...
Prevalence of CKD by risk factor<br />Am J of Kidney Diseases 39(2)Suppl 1, 2002:ppS7-S10<br />
Who is at risk for CKD:  the short list<br />Diabetes Mellitus<br />Hypertension<br />Family history of CKD<br />U.S. ethn...
The Risk of Kidney Failure is Not Uniform<br />Relative risks compared to Whites:<br />African Americans3.9 X<br />Native ...
What is GFR?<br />Glomerular filtration rate<br />For the patients, “% kidney function”<br />Excellent measure of the filt...
How to measure or estimate GFR<br />Ideal measure of kidney function<br />Iothalamate, inulin, iohexol<br />Serum level of...
How to estimate GFR<br />Creatinine clearance – approximates GFR<br />Problems include those with serum creatinine, collec...
How to estimate GFR:  use the abbreviated MDRD study equation<br />4 variable MDRD equation<br />Serum creatinine<br />Age...
Take home messages<br />eGFR &gt; 60cc/min with kidney damage is CKD<br />eGFR &lt; 60cc/min is CKD<br />Must be abnormal ...
NKDEP National Kidney Disease Education Program www.nkdep.org<br />NKF National Kidney Foundation www.kidney.org<br />
This must be a collaborative effort with primary physicians:<br />7.6 million people with GFR 30-60 mL/min/1.73 m2<br />Ab...
Prevalence*<br />GFR <br />(ml/min/1.73 m2<br />Description<br />Stage<br />%<br />N (1000s)<br />3.3<br />5,900<br /> 90...
Kidney Failure in the US<br /><ul><li> Rising prevalence
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Bernstein Oct 29 2008 Defining Ckd And Risk Factors

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Bernstein Oct 29 2008 Defining Ckd And Risk Factors

  1. 1. Defining CKD and Risk Factors<br />
  2. 2. Objectives<br />Understand the definition of CKD<br />Describe risk factors for CKD<br />Become familiar with estimated GFR (eGFR) as a measure of kidney function<br />
  3. 3. Impact of Kidney Disease in NC<br />1 million living with CKD in NC<br />11,000 people currently on dialysis in NC<br />NC ranks 10th highest in the country in prevalence of end stage renal failure (ESRD)<br />
  4. 4.
  5. 5.
  6. 6. Background<br />NKF = National Kidney Foundation<br />1995 developed clinical practice guidelines for dialysis patients <br />DOQI = Dialysis Outcomes Quality Initiative<br />1st published in 1997<br />Realization: to improve dialysis outcomes, it is necessary to improve the health status of those who are reaching ESRD<br />
  7. 7. Background<br />Fall 1999, NKF approved proposal to move the clinical practice guideline initiative into a new phase<br />Scope would include the entire spectrum of kidney disease<br />Guidelines renamed KDOQI (=Kidney Disease Outcomes Quality Initiative)<br />Centerpiece of KDOQI is 2002 “Clinical Practice Guidelines on the Evaluation, Classification, and Stratification of CKD”<br />
  8. 8. Ann Intern Med 2003; 139:137-47<br />http://www.annals.org/cgi/reprint/139/2/137.pdf<br />Am Fam Physician 2004; 70:869-76<br />http://www.aafp.org/afp/20040901/869.pdf<br />
  9. 9. NKF K/DOQI Definition of Chronic Kidney Disease<br />Structural or functional abnormalities of the kidneys for &gt;3 months, as manifested by either:<br />1. Kidney damage, with or without decreased GFR, as defined by<br />pathologic abnormalities<br />markers of kidney damage<br />urinary abnormalities (proteinuria)<br />blood abnormalities <br />imaging abnormalities<br />kidney transplantation<br />2. GFR &lt;60 ml/min/1.73 m2, with or without kidney damage<br />
  10. 10. Is the Kidney Failure Acute or Chronic?<br />Acute<br />Chronic<br />Hx normal kidney function<br />Normal sized kidneys <br />Normal echotexture<br />Normal to slightly decr. Hgb/Hct<br />intact PTH normal<br />Acute process on kidney biopsy<br />Often active urine sediment<br />Hx altered kidney function<br />Small sized kidneys<br />Increased echogenicity<br />Anemia<br />intact PTH elevated<br />Chronic scarring on kidney biopsy<br />Chronic findings on U/A<br />
  11. 11. Assessing CKD risk<br />All individuals should be assessed to determine if they are at increased risk of developing CKD<br />Individuals at increased risk of developing CKD should undergo testing for markers of kidney damage and to estimate the level of GFR<br />Those at risk, but without CKD, should be advised about risk factor reduction and undergo repeat periodic evaluation<br />Am J of Kidney Diseases 39(2)Suppl 1, 2002:ppS7-S10<br />
  12. 12. Types and Examples of Risk Factors for CKD<br />Am J of Kidney Diseases 39(2)Suppl 1, 2002:ppS7-S10<br />
  13. 13. Potential Risk Factors for Susceptibility to and Initation of CKD<br />
  14. 14. Relationship between the type of kidney disease and risk factors<br />Am J of Kidney Diseases 39(2)Suppl 1, 2002:ppS7-S10<br />
  15. 15. Prevalence of CKD by risk factor<br />Am J of Kidney Diseases 39(2)Suppl 1, 2002:ppS7-S10<br />
  16. 16. Who is at risk for CKD: the short list<br />Diabetes Mellitus<br />Hypertension<br />Family history of CKD<br />U.S. ethnicity status<br />African American<br />American Indian<br />Hispanic<br />Asian<br />Pacific Islander<br />
  17. 17. The Risk of Kidney Failure is Not Uniform<br />Relative risks compared to Whites:<br />African Americans3.9 X<br />Native Americans2.9 X<br /> Asians1.6 X<br />From NKDEP; USRDS, 2003<br />
  18. 18. What is GFR?<br />Glomerular filtration rate<br />For the patients, “% kidney function”<br />Excellent measure of the filtering capacity of the kidneys<br />Total GFR = # of nephrons x GFR of a single nephron<br />Varies according to age, gender, body size<br />
  19. 19. How to measure or estimate GFR<br />Ideal measure of kidney function<br />Iothalamate, inulin, iohexol<br />Serum level of creatinine (endogenous filtration marker) traditionally used to estimate GFR<br />Problems include: tubular secretion, generation, 50% loss of function before Cr becomes abnormal<br />
  20. 20. How to estimate GFR<br />Creatinine clearance – approximates GFR<br />Problems include those with serum creatinine, collection difficulties/inaccurate, overestimation of GFR due to tubular secretion of creatinine<br />Estimation of creatinine clearance – Cockcroft-Gault equation<br />MDRD study equation estimates GFR standardized for body surface area (BSA)<br />
  21. 21. How to estimate GFR: use the abbreviated MDRD study equation<br />4 variable MDRD equation<br />Serum creatinine<br />Age<br />Gender<br />Ethnicity<br />Easy to implement<br />Rigorously validated <br />Recommended by NKDEP, NKF, NIDDK, ASN<br />http://www.kidney.org/professionals/kdoqi/gfr_calculator.cfm <br />
  22. 22. Take home messages<br />eGFR &gt; 60cc/min with kidney damage is CKD<br />eGFR &lt; 60cc/min is CKD<br />Must be abnormal x 3 mos duration<br />Remember the short list of risk factors: the big 4<br />eGFR is a 4 variable equation based on age, gender, ethnicity, Creatinine.<br />Labcorps makes it easy for you because they tell you if the eGFR is abnormal (with one exception…)<br />
  23. 23. NKDEP National Kidney Disease Education Program www.nkdep.org<br />NKF National Kidney Foundation www.kidney.org<br />
  24. 24.
  25. 25. This must be a collaborative effort with primary physicians:<br />7.6 million people with GFR 30-60 mL/min/1.73 m2<br />About 5,000 full-time nephrologists <br />Nearly 1,500 new patients per nephrologist<br /> Therefore, 7 new patients per day per nephrologist. Obviously not possible.<br />http://www.nkdep.nih.gov/index.htm<br />
  26. 26.
  27. 27. Prevalence*<br />GFR <br />(ml/min/1.73 m2<br />Description<br />Stage<br />%<br />N (1000s)<br />3.3<br />5,900<br /> 90<br />Kidney Damage with Normal or  GFR<br />1<br />3.0<br />5,300<br />60-89<br />Kidney Damage with Mild  GFR<br />2<br />4.3<br />7,600<br />30-59<br />Moderate  GFR<br />3<br />0.2<br />400<br />15-29<br />Severe  GFR<br />4<br />0.1<br />300<br />&lt; 15 or Dialysis<br />Kidney Failure<br />5<br />Prevalence of CKD and Estimated Number of Adults with CKD in the US (NHANES 88-94)<br />*Stages 1-4 from NHANES III (1988-1994). Population of 177 million with age 20. Stage 5 from USRDS (1998), includes approximately 230,000 patients treated by dialysis, and assuming 70,000 additional patients not on dialysis. GFR estimated from serum creatinine using MDRD Study equation based on age, gender, race and calibration for serum creatinine. For Stage 1 and 2, kidney damage estimated by spot albumin-to-creatinine ratio 17 mg/g in men or 25 mg/g in women in two measurements.<br />
  28. 28.
  29. 29. Kidney Failure in the US<br /><ul><li> Rising prevalence
  30. 30. Poor outcomes
  31. 31. High cost</li></ul>2007 Annual Data Report, USRDS<br />2007 Annual Data Report, USRDS<br />

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