Chronic Kidney Disease Definition

1,932 views

Published on

0 Comments
2 Likes
Statistics
Notes
  • Be the first to comment

No Downloads
Views
Total views
1,932
On SlideShare
0
From Embeds
0
Number of Embeds
5
Actions
Shares
0
Downloads
130
Comments
0
Likes
2
Embeds 0
No embeds

No notes for slide

Chronic Kidney Disease Definition

  1. 1. Chronic Kidney Disease Definition, Early Intervention & Measurement Andrea Easom Ma, MNSc, APN, BC. CNN University of Arkansas for Medical Sciences Instructor, College of Medicine, Nephrology Division
  2. 2. Educational Objectives <ul><li>Define chronic kidney disease (CKD) </li></ul><ul><li>Identify risk factors for progression and co-morbid conditions </li></ul><ul><li>Discuss how early intervention improves outcomes during CKD progression </li></ul><ul><li>Review measurements of kidney disease </li></ul>
  3. 3. Awareness of Early-Stage CKD Is Low in the US Population *Proportion of patients who were told they had weak or failing kidneys, eGFR (mL/min/1.73 m 2 ). Coresh et al. J Am Soc Nephrol. 2005:16:180-188. <30 30+ <30 30+ <30 30+ F M Sex: Albuminuria: eGFR: 90+ 60-89 30-59 30-59 M450 © 2005 The Johns Hopkins University School of Medicine.
  4. 4. Definition of Chronic Kidney Disease AJKD 2002: 39(2)
  5. 5. Stages of Chronic Kidney Disease AJKD 2002: 39(2)
  6. 6. Definition and Stages of Chronic Kidney Disease AJKD 2002: 39(2)
  7. 7. Stages in Progression of CKD and Therapeutic Strategies AJKD 2002: 39(2)
  8. 8. Risk Factors for Adverse Outcomes of CKD AJKD 2002: 39(2)
  9. 9. Potential Risk Factors for Susceptibility to and Initiation of CKD AJKD 2002: 39(2)
  10. 10. AJKD 2002: 39(2)
  11. 11. Why Estimate GFR From SCr, Instead of Using SCr for Kidney Function? *B = black; † W = all ethnic groups other than black. GFR calculator available at: www.kidney.org/index.cfm?index=professionals. Accessed 3/28/05. 2 75 1.3 W † M 20 1 91 1.3 B* M 20 CKD Stage eGFR (mL/min/1.73 m 2 ) SCr (mg/dL) Race Gender Age 50 55 20 55 3 46 1.3 W F 3 55 1.3 B F 3 56 1.3 W F 2 61 1.3 W M
  12. 12. Stages of CKD: A Clinical Action Plan AJKD 2002: 39(2)
  13. 13. Evaluation of Proteinuria in Patients Not Known to Have Kidney Disease AJKD 2002: 39(2)
  14. 14. Diabetes The Leading Cause of Kidney Failure
  15. 15. Increased Mortality in Patients With Diabetes and CKD: 2-Year Clinical Outcomes CKD identified as ICD-9-CM diagnosis code, includes CKD from diabetes, hypertension, obstructive uropathy, and other diagnosis codes reported on USRDS ESRD registration forms. DM = diabetes mellitus; ESRD = end-stage renal disease; ICD-9-CM = International Statistical Classification of Diseases, 9th Revision, Clinical Modification. Collins et al. Kidney Int . 2003;64(suppl 87):S24-S31. + DM, - CKD - DM, +CKD + DM, + CKD Medical Cohort Patients (%) M9 © 2005 The Johns Hopkins University School of Medicine. 0 20 40 60 80 100 84.0 67.6 61.6 No Events 29.5 15.7 32.3 Death ESRD, CKD Stage 5 0.3 2.9 6.1
  16. 16. Advanced Kidney Outcomes by Year 8 of EDIC Reduced by Intensive Treatment EDIC = Epidemiology of Diabetes Interventions and Complications. * P = 0.004. Writing team for the DCCT/EDIC Research Group. JAMA. 2003;290:2159-2167. M464 © 2005 The Johns Hopkins University School of Medicine. 7 (1.0%) 4 (0.6%) Dialysis or Transplant 19 (2.8%) 5* (0.7%) Creatinine >2 mg/dL Conventional (n = 673) Intensive (n = 676) Outcome
  17. 17. Proteinuria Predicts Stroke and CHD Events in Patients With Type 2 Diabetes P <0.001 40 30 20 10 0 Stroke CHD Events 80 60 40 20 0 0.5 0.6 0.7 0.8 0.9 1.0 Survival Curves for CV Mortality Overall: P <0.001 Incidence (%) Follow-Up (mo) CHD = coronary heart disease; Prot = urinary protein excretion; CV = cardiovascular. Miettinen et al. Stroke . 1996;27:2033-2039. Prot 150-300 mg/L Prot <150 mg/L Prot >300 mg/L 0 100 M49 © 2005 The Johns Hopkins University School of Medicine.
  18. 18. Evidence for Effects of Good Glycemic Control on Complications, Including Nephropathy DCCT = The Diabetes Control and Complications Trial. DCCT Study Group. N Engl J Med . 1993;329:977-986; Ohkubo. Diabetes Res Clin Prac . 1995;28:103-117; UKPDS Study Group. Lancet . 1998;352:837-853. M463 © 2005 The Johns Hopkins University School of Medicine. Trial UKPDS (8  7%) N = 5102 Kumamoto (9  7%) N = 110 DCCT A1C: (9  7%) N = 1441 Complication – –  60% Neuropathy  24-33%  70%  54% Nephropathy  17-21%  69%  76% Retinopathy
  19. 19. Hypertension The Second Leading cause of Kidney Failure
  20. 20. Recommendations for BP and RAS Management in CKD BP = blood pressure; RAS = renin angiotensin system; CCB = calcium channel blocker; BB =  -blocker; JNC 7 = The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. ADA. Diabetes Care . 2005;28(suppl 1); Chobanian et al. JAMA. 2003;289:2560-2572; Kidney Disease Outcomes Quality Initiatives (K/DOQI). Am J Kidney Dis. 2004;43(5 suppl 1):S1-S290. EXPECT TO NEED TO USE 3+ AGENTS TO ACHIEVE GOALS Recommendations largely consistent across JNC 7, ADA, and K/DOQI M60 © 2005 The Johns Hopkins University School of Medicine. No specific preference: Diuretics then ACE-I, ARB, CCB, or BB <130/80  Diabetes  Proteinuria Diuretics then CCB or BB ACE-I or ARB <130/80  Diabetes + Proteinuria Diuretics then CCB or BB ACE-I or ARB <130/80 + Diabetes Adjunctive First Line Goal BP (mm Hg) Patient Group
  21. 21. ACEI/ARB & Reduced Risk of Rapid GFR Decline, Kidney Failure, or Death Wright et al for the AASK Study Group. JAMA. 2002;288:2421-2431. [AASK - African American Study of Kidney Disease and Hypertension] Brenner et al for the RENAAL Study Investigators. N Engl J Med. 2001;345:861-869. [RENAAL = Reduction of Endpoints in NIDDM with the Angiotensin II Antagonist Losartan] Lewis et al for the Collaborative Study Group. N Engl J Med. 2001;345:851-860. [IDNT = Irbesartan in Diabetic Nephropathy Trial.] Ramipril vs Amlodipine P = 0.004 Ramipril vs Metoprolol P = 0.04 Losartan vs Placebo P = 0.02 -38 -22 -16 Irbesartan vs Placebo P = 0.02 -20 Irbesartan vs Amlodipine P = 0.006 -23 AASK (N=1094) RENAAL (N=1513) IDNT (N=1722) © 2005 The Johns Hopkins University School of Medicine.
  22. 22. ACEIs, ARBs, and Combination Therapy Effects in Nondiabetic Nephropathy *Primary end point: doubling of SCr or kidney failure. Nakao et al. Lancet. 2003;361:117-124. P = 0.02 Trandolapril (n = 86) M35 © 2005 The Johns Hopkins University School of Medicine. Combination (n = 88) Losartan (n = 89)
  23. 23. Relationship Between Achieved BP and GFR MAP = Mean Arterial Pressure* r = 0.69 P <0.05 Untreated Hypertension 130/80 140/90 *MAP = [SBP + (2 × DBP)]/3 mm Hg. Summary of 9 studies used in figure. Parving et al. 1989; Viberti et al. 1993; Klahr et al. 1993; Hebert et al. 1994; Lebovitz et al. 1994; Moschio et al. 1996; Bakris et al. 1996; Bakris et al. 1997; GISEN Group. 1997. Bakris et al. Am J Kidney Dis. 2000;36:646-661. M465 © 2005 The Johns Hopkins University School of Medicine.
  24. 24. Anemia A Modifiable and Funded Risk Factor
  25. 25. Anemia Prevalence by CKD Stage *NHANES participants aged ≥ 20 y with anemia as defined by WHO criteria: hemoglobin (Hgb) <12 g/dL for women, and Hgb <13 g/dL for men. USRDS 2004 Annual Data Report. The data reported here have been supplied by the USRDS. The interpretation and reporting of these data are the responsibility of the author(s) and in no way should be seen as an official policy or interpretation of the U.S. government. Available at: www.usrds.org. Accessed 3/28/05. Patients With Anemia* (%) CKD Stage M71 © 2005 The Johns Hopkins University School of Medicine. NHANES III NHANES 1999-2000
  26. 26. Anemia Treatment Eligibility <ul><li>Serum Creatinine (2.0 mg/dl or above) or </li></ul><ul><li>Creatinine Clearance (45 ml/min or below) and </li></ul><ul><li>Hemoglobin (11g/dl or below) or </li></ul><ul><li>Hematocrit (33% or below) or </li></ul><ul><li>Symptoms of anemia </li></ul>
  27. 27. Consequences of Anemia in CKD <ul><li>Reduced oxygen delivery to tissues </li></ul><ul><li>Decrease in Hgb compensated by increased cardiac output </li></ul><ul><li>Progressive cardiac damage and progressive renal damage 1 </li></ul><ul><li>Increased mortality risk 2 </li></ul><ul><li>Reduced quality of life (QOL) 3 </li></ul><ul><ul><li>Fatigue </li></ul></ul><ul><ul><li>Diminished exercise capacity </li></ul></ul><ul><ul><li>Reduced cognitive function </li></ul></ul><ul><li>Left ventricular hypertrophy (LVH) 4 </li></ul>1. Silverberg et al. Blood Purif. 2003;21:124-130. 2. Collins et al. Semin Nephrol. 2000;20:345-349; 3. The US Recombinant Human Erythropoietin Study Group. Am J Kidney Dis. 1991;18:50-59; 4. Levin. Semin Dial. 2003;16:101-105. M76 © 2005 The Johns Hopkins University School of Medicine.
  28. 28. Clinical Benefit of Anemia Correction: CHF and CKD Patients With CHF and Anemia (n = 126, 91% CKD) NYHA class = New York Heart Association classification; SOB = shortness of breath. Silverberg et al. Perit Dial Int. 2001;21(suppl 3):S236-S240. M83 © 2005 The Johns Hopkins University School of Medicine. 76 75 Diastolic BP (mm Hg) 131 132 Systolic BP (mm Hg) 0.2 3.7 Hospitalizations 2.7 8.9 Fatigue/SOB index (0-10) 2.7 3.8 NYHA class (0-4) 0.27 -0.95 ∆ GFR (mL/min/mo) 2.3 2.4 Serum creatinine (g/dL) 13.1 10.3 Hgb (g/dL) After Before Parameter
  29. 29. Secondary Hyperparathyroidism An Early and Modifiable Complication of CKD
  30. 30. Calcitriol Decline and iPTH Elevation as CKD Progresses N = 150. iPTH = intact PTH. Adapted from Martinez et al. Nephrol Dial Transplant. 1996;11(suppl 3):22-28. eGFR (mL/min/1.73 m 2 ) 15 25 35 45 55 65 75 85 95 105 100 200 300 400 iPTH (pg/mL) Calcitriol 1,25(OH) 2 D 3 (pg/mL) Stage 3 7.4 million Stage 2 5.7 million Stage 4 300,000 CKD Stage 1 5.6 million 25 65 Low-Normal Calcitriol High-Normal PTH M236 © 2005 The Johns Hopkins University School of Medicine. 0 10 20 30 40 50
  31. 31. Feedback Loops in SHPT Ca = calcium; CVD = cardiovascular disease; P = phosphorus. Courtesy of Kevin Martin, MB, BCh. © 2005 The Johns Hopkins University School of Medicine.  PTH Bone Disease Fractures Bone pain Marrow fibrosis Erythropoietin resistance  Serum P <ul><li>1,25D </li></ul><ul><li>Calcitriol </li></ul>Renal Failure  PTH Systemic Toxicity CVD Hypertension Inflammation Calcification Immunological <ul><li>25D </li></ul> Ca ++ Decreased Vitamin D Receptors and Ca-Sensing Receptors
  32. 32. Bone Loss Correlates With Severity of SHPT in CKD Stages 3 and 4 * P< 0.05 compared with patients with PTH in the normal range. Z-Score = comparison to the mean value for women at a similar risk, including age, weight, and ethnicity. Rix et al. Kidney Int. 1999;56:1084-1093. * * * M93 © 2005 The Johns Hopkins University School of Medicine.
  33. 33. Bone-Fracture Rate Increases as CKD Progresses: Fractures in Patients on Dialysis *Ratio of observed incidence of hip fracture in patients with kidney failure to expected incidence of hip fracture in the general population. Adapted from Alem et al. Kidney Int . 2000;58:396-399. 0 5 10 100 <45 45-54 55-64 65-74 75-84 Total Age (y) Observed/Expected Incidence of Hip Fracture* Male Relative Risk = 4.4 Female Relative Risk = 4.4 Overall 15 20 80 100 87 99 25 20 10 10 7.5 6.4 2.4 2.5 4.4 4.4 M305 © 2005 The Johns Hopkins University School of Medicine.
  34. 34. Cardiovascular Outcomes Worsen With CKD Progression: 3-Y Follow-Up by eGFR Levels CHF = congestive heart failure. Anavekar et al. N Engl J Med. 2004;351:1285-1295. Estimated Event Rate (%)  75 60-74 45-59 <45 P <0.001 eGFR (mL/min/1.73 m 2 ) M42 © 2005 The Johns Hopkins University School of Medicine.
  35. 35. Why Classify Severity as the Level of GFR? AJKD 2002: 39(2)
  36. 36. Guideline 4. Estimation of GFR AJKD 2002: 39(2)
  37. 37. Guideline 4. Estimation of GFR (cont’d) AJKD 2002: 39(2)
  38. 38. Guideline 4. Estimation of GFR (cont’d) AJKD 2002: 39(2)
  39. 39. Advantages of Estimating GFR Using Equations AJKD 2002: 39(2)
  40. 40. Serum Creatinine Corresponding to GFR of 60 mL/min/1.73 m2 AJKD 2002: 39(2)
  41. 41. Relationship of Creatinine Clearance and Serum Creatinine with GFR (Inulin Clearance) in Patients with Glomerular Disease AJKD 2002: 39(2)
  42. 42. Estimates of GFR vs. Measured GFR in MDRD Study Baseline Cohort AJKD 2002: 39(2)
  43. 43. Accuracy of Different Estimates of GFR in Adults AJKD 2002: 39(2)
  44. 44. Prevalence of Individuals at Increased Risk for CKD AJKD 2002: 39(2)
  45. 45. Awareness of Early-Stage CKD Is Low in the US Population *Proportion of patients who were told they had weak or failing kidneys, eGFR (mL/min/1.73 m 2 ). Coresh et al. J Am Soc Nephrol. 2005:16:180-188. <30 30+ <30 30+ <30 30+ F M Sex: Albuminuria: eGFR: 90+ 60-89 30-59 30-59 M450 © 2005 The Johns Hopkins University School of Medicine.
  46. 46. Summary <ul><li>Over 20 millions Americans have some degree of CKD & few are aware of it. </li></ul><ul><li>There are interventions to slow the progression and treat the complications that are associated with CKD. </li></ul><ul><li>Reporting eGFR can help alert health care providers that their patient may have CKD so further workup, education and interventions can be done. </li></ul>

×