Chronic Kidney Disease (CKD)

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Chronic Kidney Disease (CKD)

  1. 1. Chronic Kidney Disease (CKD) Larry Lehrner, PhD, MD, FACP Kidney Specialists of Southern Nevada llehrner@ksosn.com NV ACP Meeting 16 Jan 2010 Disclosures: Board relationships- DoctorsXL Research support- Amgen, Fibrogen, Genzyme,Affymax Consulting- Healthinsight, Pharmerica Speakers’ Bureau- Amgen, Advanced Health Media Income relationships- dialysis unit JVs with DaVita Corp stock > 50K- Roche, Siemens
  2. 2. CKD Outline of Presentation • Renal Function • eGFR • CKD- the problem- patients and cost • What the Nephrologist Should Treat- the ideal vs. the achieved • Have we slowed the progression to ESRD
  3. 3. CKD Outline of Presentation • Renal Function • eGFR • CKD- the problem- patients and cost • What the Nephrologist Should Treat- the ideal vs. the achieved • Have we slowed the progression to ESRD and/or decreased mortality in CKD
  4. 4. CKD Audience Participation What physiological functions do the kidneys perform?
  5. 5. Physiological Kidney Functions Function Complication Due to CKD • Filter waste products • Uremia • Produce EPO • Anemia • Regulate Acid-Base • Acidosis • Control fluid volume • CHF / Pulmonary Edema • Produce active Vit D • 2° Hyperparathyroidism • Regulate Na, K, PO4 • Hyperkalemia, HyperPO4 • Regulate Blood Pressure • Hypertension
  6. 6. CKD Outline of Presentation • Renal Function • eGFR • CKD- the problem- patients and cost • What the Nephrologist Should Treat- the ideal vs. the achieved • Have we slowed the progression to ESRD and/or decreased mortality in CKD
  7. 7. CKD Audience Participation How is renal dysfunction detected?
  8. 8. CKD How to Detect Renal Disease • Serum BUN and creatinine • Estimated GFR (Glomerular Filtration Rate) • Urinalysis- protein/blood • Renal Imaging • Renal Biopsy
  9. 9. CKD Serum Creatinine 1.3 mg/dl Normal??? Abnormal???
  10. 10. CKD Serum Creatinine 1.3- Normal or Abnormal ? Abnormal Normal Abnormal Normal ????
  11. 11. CKD Serum Creatinine Context is Everything! 1.3 mg/dl Can be normal or abnormal • Age • Sex • Muscle Mass • Body Parts- amputations • Race • Prior value
  12. 12. CKD Doubling of Scr = 50% decrease Ccr 1.2 9 8 1 7 0.8 6 1/Scr 5 0.6 Scr 4 0.4 3 2 0.2 1 0 0 1998 1999 2000 2001 2002 1/S c r S erum Creatinine
  13. 13. CKD Estimating GFR Ann Intern Med 2003;139:137-147
  14. 14. CKD Outline of Presentation • Renal Function • eGFR • CKD- the problem- patients and cost • What the Nephrologist Should Treat- the ideal vs. the achieved • Have we slowed the progression to ESRD and/or decreased mortality in CKD
  15. 15. Prevalence of Chronic Kidney Disease 1 in 9 US adults have CKD Another 20 million are at increased risk eGFR <15 or dialysis Stage 5 n=300,000 Stage 4 eGFR between 15-29 n=400,000 eGFR between 30-59 n=7,600,000 Stage 3 Stage 2 eGFR between 60-89 n=5,300,000 Stage 1 eGFR >90 n=5,900,000 Coresh J, et al. Am J Kidney Dis. 2003;41:1-12.
  16. 16. Overall expenditures for CKD, by dataset Figure 9.2 (Volume 1) USRDS 2009 ADR Period prevalent general Medicare & MarketScan patients.
  17. 17. Causes of CKD Glomerulonephritis Interstitial nephritis 11% 4% 18% Other 27% Hypertension 40% Diabetes USRDS 1999. Annual Report. Am J Kid Dis.:S40.
  18. 18. CKD Identification CKD Risk Factors Indicators of Kidney Damage • Hypertension • Proteinuria • Diabetes • Hematuria • Age >60 • Other urine sediment abnormalities • Family history of CKD • Structural (imaging) abnormalities • Nephrotoxic drug exposure, including • GFR <60 mL/min* NSAIDs • Other abnormal blood tests† • Cardiovascular disease • History of acute renal failure • Autoimmune disease • Urologic disorders • Systemic infection • Cancer • Ethnic minority *GFR is preferred over creatinine alone for assessing kidney function. †See “Potential Complications” in CKD: Identification and Action Plan.
  19. 19. CKD Audience Participation The majority of patients with CKD have what signs and symptoms?
  20. 20. CKD Usual Signs and Symptoms NONE
  21. 21. CKD
  22. 22. CKD Audience Participation After the diagnosis of CKD there are 3 possible outcomes. Please rank the expected frequency of the outcomes from high to low 2-5 years after the Dx of CKD ? A. Progress to End Stage Renal Disease(ESRD) B. Be alive without ESRD C. Die
  23. 23. CKD Bad condition high rate of morbidity and mortality
  24. 24. CKD Patients Are More Likely to Die Than Progress to ESRD Percentage Who Remained Event-Free vs Death vs. Developed ESRD During 2-Year Follow-up. Patients had their first Nephrology consult at an outpatient clinic 100% 80% % of Patients 61% 68% Event Free 60% 84% 90% ESRD 40% Death 18% 11% 20% 4% 22% 1% 20% 8% 12% 0% No DM, No DM, No CKD No DM, CKD DM, CKD CKD Status at Entry Period Medicare 5% sample 1996-1997, Two year follow-up, adjusted for age, gender, and race Analysis performed by Minneapolis Medical Research Foundation
  25. 25. CKD Patients Are More Likely to Die Than Progress to ESRD Percentage Who Remained Event-Free vs Death vs. Developed ESRD During 2-Year Follow-up. Patients had their first Nephrology consult at an inpatient hospital 100% 80% 52% 48% 56% 55% % of Patients 60% Event Free ESRD 2% 4% 9% 40% 5% Death 20% 42% 44% 40% 43% 0% No DM, No DM, No CKD No DM, CKD DM, CKD CKD Status at Entry Period Medicare 5% sample 1996-1997, Two year follow-up, adjusted for age, gender, and race Analysis performed by Minneapolis Medical Research Foundation
  26. 26. A Separate Study With a 5-Year Follow-up Supports The Same Conclusion Percentage Who Remained Event-Free vs Death vs Developed ESRD During 5-Year Follow-up 100% 15% 10% 7% 90% 16% 80% 28% % of Patients 70% Disenrolled 60% 64% Event free 63% 20% 50% 75% RRT 40% Died 30% 1% 46% 20% 10% 20% 24% 10% 0% Stage 1 Stage 2 Stage 3 Stage 4 Keith et al. J Am Soc Nephrol. 13:620A, 2002.
  27. 27. Relative risk of death in Medicare patients age 66 & older, by at-risk group Figure 5.22 (Volume 1) Point prevalent patients on January 1 of each year, age 66 & older. Comorbidities identified from claims in the prior year; exclude patients enrolled an HMO, with Medicare as secondary payor, or diagnosed with ESRD in the prior year. Followed from January 1 to December 31 of each year, censored at ESRD date and the end of Medicare entitlement. Results are from multivariable USRDS 2009 ADR Cox regressions.
  28. 28. Predictors of mortality in Medicare patients age 66 & older, by age, gender, race, at- risk group, & comorbidity Table 5.b (Volume 1) 2003 2005 2007 RR CI RR CI RR CI 66–69 1 1 1 70–74 1.33 1.29 - 1.38 1.34 1.29 - 1.38 1.35 1.3 - 1.4 75–84 2.34 2.28 - 2.42 2.38 2.31 - 2.46 2.38 2.31 - 2.46 85+ 6.30 6.11 - 6.49 6.43 6.24 - 6.62 6.34 6.15 - 6.55 Male 1.16 1.14 - 1.17 1.14 1.12 - 1.15 1.13 1.11 - 1.15 Female 1.00 1.00 1.00 White 1.00 1.00 1.00 African American 1.13 1.1 - 1.16 1.16 1.13 - 1.19 1.15 1.12 - 1.18 Other 0.87 0.83 - 0.9 0.82 0.79 - 0.86 0.85 0.82 - 0.89 No CKD, DM, or CVD 1.00 1.00 1.00 Point prevalent on January CKD (NDM, non-CVD) 1.99 1.83 - 2.17 1.60 1.47 - 1.74 1.72 1.6 - 1.85 1 of each year, age 66 & DM (non-CKD, non CVD) 1.23 1.19 - 1.28 1.22 1.18 - 1.27 1.12 1.08 - 1.16 older. Comorbidities CVD (non-CKD, non-DM) 1.84 1.8 - 1.88 1.81 1.78 - 1.85 1.80 1.76 - 1.83 identified from claims in CKD+DM 2.10 1.86 - 2.37 2.05 1.84 - 2.28 1.80 1.63 - 1.98 prior year, and exclude CKD+CVD 3.10 2.98 - 3.22 2.85 2.74 - 2.96 2.77 2.67 - 2.86 patients enrolled an HMO, DM+CVD 2.45 2.39 - 2.51 2.36 2.3 - 2.42 2.19 2.13 - 2.25 with Medicare as secondary CKD+DM+CVD 4.07 3.91 - 4.24 3.57 3.43 - 3.71 3.35 3.23 - 3.47 payor, or diagnosed with Hypertension 0.81 0.8 - 0.82 0.81 0.8 - 0.83 0.81 0.8 - 0.83 ESRD in the prior year Liver disease 1.70 1.6 - 1.81 1.79 1.69 - 1.9 1.84 1.73 - 1.95 Followed from January 1 to GI disease 1.24 1.21 - 1.28 1.26 1.22 - 1.3 1.25 1.21 - 1.29 December 31 of the year, Cancer 1.86 1.83 - 1.9 1.84 1.8 - 1.87 1.80 1.76 - 1.83 censored at ESRD date and COPD 1.98 1.94 - 2.01 1.96 1.93 - 1.99 1.95 1.92 - 1.99 the end of Medicare Anemia 1.70 1.67 - 1.73 1.71 1.68 - 1.74 1.72 1.69 - 1.75 entitlement. Results are from multivariable Cox regressions. USRDS 2009 ADR
  29. 29. Unadjusted & adjusted all-cause hospitalization rates in the Medicare & MarketScan populations, by dataset & CKD status Figure 5.1 (Volume 1) Medicare: point prevalent patients on January 1 of the year. During the prior year, patients are continuously enrolled in Medicare parts A & B with no HMO coverage. Medicare patients are age 66+ on December 31 of the prior year. MarketScan: point prevalent patients on January 1 of the year, continuously enrolled in a fee-for-service plan during the prior year. Includes MarketScan patients age 50-64 on December 31 of the prior year. For both populations, CKD is defined during the prior year, patients diagnosed with ESRD before the start of follow-up are excluded, and follow-up for admissions begins on January 1 of the year. Adjustment for gender, prior hospitalization, cardiovascular disease, diabetes, COPD, hypertension, liver disease, gastrointestinal disease, cancer, and anemia; 2005 Medicare cohort used as reference. USRDS 2009 ADR
  30. 30. Overall PPPM costs for CKD, by dataset Figure 9.6 (Volume 1) Period prevalent general Medicare & USRDS 2009 ADR MarketScan patients.
  31. 31. Complications Associated With CKD • Anemia • Hypertension • Cardiovascular disease • Diabetes • Osteodystrophy • Malnutrition • Metabolic acidosis • Dyslipidemia Zabetakis. Am J Kidney Dis. 2000;36(suppl 3):S31.
  32. 32. CKD Outline of Presentation • Renal Function • eGFR • CKD- the problem- patients and cost • What the Nephrologist Should Treat- the ideal vs. the achieved • Have we slowed the progression to ESRD and/or decreased mortality in CKD
  33. 33. CKD Early Treatment Can Make a Difference Let’s Change the Paradigm of Treatment Brenner, et al., 2001
  34. 34. CKD What the Nephrologist Should be Treating Hypertension •Anti-hypertensive Rx- target BP 130/85 without proteinuria target BP 125/75 with proteinuria •ACEI/ARB benefits in addition to lowering BP
  35. 35. CKD patients with at least one claim forACE-Is/ ARBs/renin inhibitors in the twelve months following the entry period, by year & dataset Figure 4.15 (Volume 1) Point prevalent CKD patients age 20-64 at beginning of study period. CKD & all other comorbidities defined at entry period, one year before study period. Follow-up censored at ESRD. USRDS 2009 ADR
  36. 36. CKD What the Nephrologist Should be Treating Hyperparathyroidism Synthesis of Active Vitamin D Vitamin D3 Liver 25-OH-cholecalciferol Kidney (1α-hydroxylase) 1,25-(OH)2-cholecalciferol (calcitriol) Schomig. Nephrol Dial Transplant. 2000;15(suppl 5):18.
  37. 37. CKD What the Nephrologist Should be Treating Hyperparathyroidism Pathophysiology of Secondary HPT PTH PTH Ca2+ Systemic Toxicity Bone Disease FGF23 Vit D P Renal Failure
  38. 38. CKD What the Nephrologist Should be Treating Hyperparathyroidism
  39. 39. CKD What the Nephrologist Should be Treating Hyperparathyroidism PTH,PO4 and Ca abnormalities in CKD 3-5 % patients 90 80 70 60 50 PTH 40 PO4 30 Ca 20 10 0 CKD3 CDK4 CDK5 Levin A, et al. KI 2007;71:31-38
  40. 40. Cumulative probability of CKD patients receiving calcium/phosphorus testing in a calendar year, by year & dataset Figure 4.10 (Volume 1) General Medicare patient (age 66 & older) & Ingenix i3 patients (age 50-64) with CKD. USRDS 2009 ADR
  41. 41. Cumulative probability of CKD patients receiving parathyroid hormone testing in a calendar year, by year & dataset Figure 4.11 (Volume 1) General Medicare patient (age 66 & older) & Ingenix i3 patients USRDS 2009 ADR (age 50-64) with CKD.
  42. 42. CKD What the Nephrologist Should be Treating Acidosis Acid/Base Balance Renal NH4+ Excretion 40 mEq/day Endogenous Renal Net Acid H+ Excretion Production Renal T.A. 70 mEq/day 70 mEq/day Excretion 30 mEq/day Normal Acid/Base Balance [HCO3-] = 24 mEq/L TA=Titratable acid Alpern. Am J Kidney Dis. 1997;29:291.
  43. 43. CKD What the Nephrologist Should be Treating Acidosis Treatment of Metabolic Acidosis • Goal – Serum HCO3- > 21 mEq/L – pH > 7.35 • Agents – Sodium bicarbonate tablets • (650 mg = ~8 mEq HCO3-) – Sodium citrate (Shohl’s solution) • Dose of HCO3 – 1.0-1.5 mEq/kg/day – Dependent upon initial serum HCO3- and degree of renal insufficiency Dubose TD. Harrison’s Principles of Internal Medicine. 1998:277. Facts and Comparisons. 1977; 726-727.
  44. 44. CKD What the Nephrologist Should be Treating Acidosis Treatment of Metabolic Acidosis Dubose TD. Harrison’s Principles of Internal Medicine. 1998:277. Ione de Brito-Ashurst, JASN Express. Published on July 16, 2009 as doi: 10.1681/ASN.2008111205 Facts and Comparisons. 1977; 726-727.
  45. 45. CKD What the Nephrologist Should be Treating Anemia Anemia Is a Mortality Multiplier Medicare 5% Sample 1996-1997 2-Year Follow-up, Adjusted for Age, Gender, and Race 8 7.3 7 6 Relative Risk 5 3.7 3.7 4 4 2.9 3 2 2 2 1.5 1 1 0 F e ia D ia ia s M ia on H te K m m em D m C C be F/ ne ne N e An An H ia A A C D F/ D/ D/ H K K C C /C HF /C M Medicare 5% sample 1996-1997, Two year follow-up, adjusted for age, gender, and race Analysis performed by Minneapolis Medical Research Foundation D
  46. 46. CKD What the Nephrologist Should be Treating Anemia Anemia Develops Early in CKD Kazmi, Am J Kid Dis, 2001, 38:803-812 Greater Boston Area Chart Audit
  47. 47. Cumulative probability of CKD patients receiving hemoglobin testing in a calendar year, by year & dataset Figure 4.14 (Volume 1) General Medicare patient (age 66 & older) & Ingenix i3 patients (age 50-64) with CKD. USRDS 2009 ADR
  48. 48. CKD patients with anemia & with at least one claim for EPO or DPO in the twelve months following the disease defining entry period, by year & dataset Figure 4.20 (Volume 1) Point prevalent CKD patients age 20-64 at beginning of study period. CKD & all other comorbidities defined at entry period, one year before study period. Follow-up censored at ESRD. USRDS 2009 ADR
  49. 49. CKD What the Nephrologist Should be Treating Anemia Impact of Anemia on CKD patients •Lethargy1 •Weakness1,4 •Confusion1 •Shortness of breath1,4,5 •Cardiac enlargement2,3 •Palpitations4,5 •Angina1,5 •Impaired libido/impotence4 •Impaired cognition4 •Headache4,5 •Impaired immune system4 •Pallor4,5 •Tinnitus4,5 •Edema4,5 •Reduced exercise capacity4 •Paresthesia in fingers and toes5 1. Hoffbrand AV et al. Essential Hematology,1993; 2. Levin A et al. Am J Kidney Dis. 1999;34:125- 134; 3. Foley RN et al. Am J Kidney Dis. 1998;28:53-61; 4. Ludwig H et al. Semin Oncol. 2001;28(suppl 8):7-14; 5. Mackie MJ et al. In: Edwards CRW et al, eds. Davidson’s Principles and Practice of Medicine, 1995.
  50. 50. CKD What the Nephrologist Should be Treating Anemia Impact of Anemia on CKD 3. Intervention makes a difference 1.00 Proportion Surviving Unadjusted 0.98 0.96 0.94 Hgb ≥ 13.0 0.92 12.0 ≤ Hgb < 13.0 11.0 ≤ Hgb < 12.0 0.90 10.0 ≤ Hgb < 11.0 0.88 9.0 ≤ Hgb < 10.0 0.86 Hgb < 9.0 0.84 0.82 0.80 0 15 30 45 60 75 90 105 120 135 150 165 180 Follow-Up Time (days) Ofsthun, N. Kidney Int. 2003;63(5):1908-14. Used with permission from Kidney International.
  51. 51. CKD What the Nephrologist Should be Treating Anemia Does ESA Rx Made a Difference? CHIOR Trial High Hgb ` 13 vs. Low Hgb ` 11 Singh A et al. N Engl J Med 2006;355:2085-2098 Figure 3. Kaplan–Meier Estimates of the Probability of the Primary Composite End Point and Secondary End Points of Individual Components — Hospitalization for Congestive Heart Failure (CHF) without Renal Replacement Therapy (RRT), Myocardial Infarction, Stroke, and Death.Panel A shows that the largest separation between the two groups in the primary composite end point occurred at 15 months. At that time, the Kaplan–Meier estimate of the difference in cumulative event rates between the two groups reached 4.7 percentage points (15.8% in the high-hemoglobin group vs. 11.1% in the low- hemoglobin group). After 15 months, the difference between the two groups remained constant, with 752 patients (52.5%) remaining in the study (355 in the high-hemoglobin group and 397 in the low-hemoglobin group). There were no significant differences between the two groups in the four individual components of the primary composite end point (Panels B, C, D, and E). However, the hazard ratios for death and hospitalization for CHF had strong trends toward a higher risk in the high-hemoglobin group than in the low-hemoglobin group.
  52. 52. CKD What the Nephrologist Should be Treating Anemia Does ESA Rx Made a Difference? TREAT Trial Darb Hgb ` 12.5 vs Placebo Hgb ~ 10.5-11 Pfeffer MA et al. N Engl J Med 2009;361:2019-2032
  53. 53. CKD What the Nephrologist Should be Treating Anemia Impact of Anemia on CKD Anemia Kills But be humble- treating it does not seem to improve outcomes! Why?- unknown ?? Total burden of disease- Anemia is only a marker of underlying disease
  54. 54. CKD What the Nephrologist Should be Treating Preparation for RRT CKD ESRD • When to initiate Renal Replacement Therapy (RRT) – Diabetics- eGFR <=15 ml/min – Non-diabetics- eGFR <=10 ml/min – OR symptoms • Types of RRT – Hemodialysis – Peritoneal Dialysis – Kidney Transplant ESRD = End Stage Renal Disease
  55. 55. Pre-ESRD care, 2007 Figure p.11 (Volume 2) Incident ESRD patients, 2007, with new (revised edition) Medical Evidence forms. USRDS 2009 ADR
  56. 56. CKD The Nephrologists’ Ask of the Primary Care Physician Form a collaboration with your Nephrologist of choice and co-manage your patient with the Nephrologist when your patient reaches CKD3 or higher
  57. 57. Diagnosis of CKD, physician visits, & nephrology referrals prior to ESRD, 2007 Figure 7.1 (Volume 1) USRDS 2009 ADR Incident ESRD patients, 2007
  58. 58. Percent of patients with one or more CKD claims prior to ESRD, by source of claim & dataset, 2007 Figure 7.2 (Volume 1) Incident ESRD patients, 2007, with coverage for two years prior. CKD claims represent claims from any source with a diagnosis USRDS 2009 ADR for CKD.
  59. 59. Percent of patients with one or more Nephrologist visits prior to ESRD, by source of claim & dataset, 2007 Figure 7.4 (Volume 1) USRDS 2009 ADR Incident ESRD patients, 2007, with coverage for two years prior.
  60. 60. Percent of patients with one or more primary care physician visits prior to ESRD, by source of claim & dataset, 2007 Figure 7.6 (Volume 1) Incident ESRD patients, 2007, with coverage for two years prior. USRDS 2009 ADR
  61. 61. Per person per month CKD expenditures, by diagnosis & dataset Figure 9.7 (Volume 1) USRDS 2009 ADR Period prevalent general Medicare & MarketScan patients.
  62. 62. Cumulative probability of a CKD claim, by dataset & at-risk group Figure 4.2 (Volume 1) General Medicare patients (age 66 & older), & MarketScan & Ingenix i3 patients (age 50-64), surviving all of 2007 with Medicare as primary payor (and not enrolled in an HMO); age 66 or older; without CKD or ESRD in 2006. CKD, DM, & CVD identified from claims. USRDS 2009 ADR
  63. 63. Cumulative probability of a Nephrologist claim, by dataset & at-risk group Figure 4.3 (Volume 1) General Medicare patients (age 66 & older), & MarketScan & Ingenix i3 patients (age 50-64), surviving all of 2007 with Medicare as primary payor (and not enrolled in an HMO); age 66 or older; without CKD or ESRD in 2006. CKD, DM, & CVD identified from claims. USRDS 2009 ADR
  64. 64. Cumulative probability of a CKD patient having a Nephrologist claim, by dataset & at-risk group Figure 4.4 (Volume 1) General Medicare patients (age 66 & older), & MarketScan & Ingenix i3 patients (age 50-64), surviving all of 2007 with Medicare as primary payor (and not enrolled in an HMO); age 66 or older; without CKD or ESRD in 2006. CKD, DM, & CVD identified from claims. USRDS 2009 ADR
  65. 65. Cumulative probability of CKD patients receiving creatinine testing in a calendar year, by year & dataset Figure 4.9 (Volume 1) General Medicare patient (age 66 & older) & Ingenix i3 patients (age 50-64) with CKD. USRDS 2009 ADR
  66. 66. Percent of patients with one or more serum creatinine tests prior to ESRD, by year & dataset Figure 7.7 (Volume 1) Incident ESRD patients, 2007, with coverage for two years USRDS 2009 ADR prior.
  67. 67. Diabetic patients receiving an annual urinary microalbumin measurement, by race/ethnicity Figure hp.25 (Volume 2) General Medicare patients diagnosed with CKD in each year, age 65 & older at the beginning of each year, alive & continuously enrolled in Medicare inpatient/outpatient & physician/supplier program through the whole year. Patients enrolled in an HMO or diagnosed with ESRD are excluded. Testing checked during each year. USRDS 2009 ADR
  68. 68. Cumulative probability of a physician visit within one year of CKD diagnosis, by dataset & physician specialty: all CKD Figure 4.5 (Volume 1) General Medicare patients (age 66 & older), & MarketScan & Ingenix i3 patients (age 50-64), surviving all of 2007 with Medicare as primary payor (and not enrolled in an HMO); age 66 or older; without ESRD in 2006. CKD, DM, CVD, & USRDS 2009 ADR Nephrologist visits identified from claims in 2006.
  69. 69. Cumulative probability of a physician visit within one year of CKD diagnosis, by dataset & physician specialty: CKD + DM Figure 4.6 (Volume 1) General Medicare patients (age 66 & older), & MarketScan & Ingenix i3 patients (age 50-64), surviving all of 2007 with Medicare as primary payor (and not enrolled in an HMO); age 66 or older; without ESRD in 2006. CKD, DM, & USRDS 2009 ADR physician visits identified from claims in 2006.
  70. 70. Cumulative probability of a physician visit within one year of CKD diagnosis, by dataset & physician specialty: CKD + CVD Figure 4.7 (Volume 1) General Medicare patients (age 66 & older), & MarketScan & Ingenix i3 patients (age 50-64), surviving all of 2007 with Medicare as primary payor (and not enrolled in an HMO); age 66 or older; without ESRD in 2006. CKD, CVD, & USRDS 2009 ADR physician visits identified from claims.
  71. 71. CKD Outline of Presentation • Renal Function • eGFR • CKD- the problem- patients and cost • What the Nephrologist Should Treat- the ideal vs. the achieved • Have we slowed the progression to ESRD and/or decreased mortality in CKD
  72. 72. ESRD incident counts & adjusted rates, by race Figure 2.9 Incident ESRD patients; rates adjusted for age & gender. USRDS 2007 ADR
  73. 73. ESRD incident counts & adjusted rates, by primary diagnosis Figure 2.11 Incident ESRD patients; rates adjusted for age, gender, & race. USRDS 2007 ADR
  74. 74. Relative risk of death in Medicare patients age 66 & older, by at-risk group Figure 5.22 (Volume 1) Point prevalent patients on January 1 of each year, age 66 & older. Comorbidities identified from claims in the prior year; exclude patients enrolled an HMO, with Medicare as secondary payor, or diagnosed with ESRD in the prior year. Followed from January 1 to December 31 of each year, censored at ESRD date and the end of Medicare entitlement. Results are from multivariable USRDS 2009 ADR Cox regressions.
  75. 75. CKD Reducing Mortality • Early Detection of CKD • Treat BP • Treat DM • Treat Acidosis • Treat Secondary Hyperparathyroidism • Treat Anemia (?)
  76. 76. Chronic Kidney Disease (CKD) Larry Lehrner, PhD, MD, FACP Kidney Specialists of Southern Nevada llehrner@ksosn.com NV ACP Meeting 16 Jan 2010 The End- Thank you for your attention Disclosures: Board relationships- DoctorsXL Research support- Amgen, Fibrogen, Genzyme,Affymax Consulting- Healthinsight, Pharmerica Speakers’ Bureau- Amgen, Advanced Health Media Income relationships- dialysis unit JVs with DaVita Corp stock > 50K- Roche, Siemens

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