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Bernstein Oct 29 2008 Defining Ckd And Risk Factors
Bernstein Oct 29 2008 Defining Ckd And Risk Factors
Bernstein Oct 29 2008 Defining Ckd And Risk Factors
Bernstein Oct 29 2008 Defining Ckd And Risk Factors
Bernstein Oct 29 2008 Defining Ckd And Risk Factors
Bernstein Oct 29 2008 Defining Ckd And Risk Factors
Bernstein Oct 29 2008 Defining Ckd And Risk Factors
Bernstein Oct 29 2008 Defining Ckd And Risk Factors
Bernstein Oct 29 2008 Defining Ckd And Risk Factors
Bernstein Oct 29 2008 Defining Ckd And Risk Factors
Bernstein Oct 29 2008 Defining Ckd And Risk Factors
Bernstein Oct 29 2008 Defining Ckd And Risk Factors
Bernstein Oct 29 2008 Defining Ckd And Risk Factors
Bernstein Oct 29 2008 Defining Ckd And Risk Factors
Bernstein Oct 29 2008 Defining Ckd And Risk Factors
Bernstein Oct 29 2008 Defining Ckd And Risk Factors
Bernstein Oct 29 2008 Defining Ckd And Risk Factors
Bernstein Oct 29 2008 Defining Ckd And Risk Factors
Bernstein Oct 29 2008 Defining Ckd And Risk Factors
Bernstein Oct 29 2008 Defining Ckd And Risk Factors
Bernstein Oct 29 2008 Defining Ckd And Risk Factors
Bernstein Oct 29 2008 Defining Ckd And Risk Factors
Bernstein Oct 29 2008 Defining Ckd And Risk Factors
Bernstein Oct 29 2008 Defining Ckd And Risk Factors
Bernstein Oct 29 2008 Defining Ckd And Risk Factors
Bernstein Oct 29 2008 Defining Ckd And Risk Factors
Bernstein Oct 29 2008 Defining Ckd And Risk Factors
Bernstein Oct 29 2008 Defining Ckd And Risk Factors
Bernstein Oct 29 2008 Defining Ckd And Risk Factors
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Bernstein Oct 29 2008 Defining Ckd And Risk Factors

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

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