Your SlideShare is downloading. ×
0
(ppt)
(ppt)
(ppt)
(ppt)
(ppt)
(ppt)
(ppt)
(ppt)
(ppt)
(ppt)
(ppt)
(ppt)
(ppt)
(ppt)
(ppt)
(ppt)
(ppt)
(ppt)
(ppt)
(ppt)
(ppt)
(ppt)
(ppt)
(ppt)
Upcoming SlideShare
Loading in...5
×

Thanks for flagging this SlideShare!

Oops! An error has occurred.

×
Saving this for later? Get the SlideShare app to save on your phone or tablet. Read anywhere, anytime – even offline.
Text the download link to your phone
Standard text messaging rates apply

(ppt)

1,241

Published on

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

  • Be the first to like this

No Downloads
Views
Total Views
1,241
On Slideshare
0
From Embeds
0
Number of Embeds
0
Actions
Shares
0
Downloads
43
Comments
0
Likes
0
Embeds 0
No embeds

Report content
Flagged as inappropriate Flag as inappropriate
Flag as inappropriate

Select your reason for flagging this presentation as inappropriate.

Cancel
No notes for slide

Transcript

  • 1. Chronic Kidney Disease-Related Mineral and Bone Disorder: Public Health Problem Kerry Willis PhD National Kidney Foundation
  • 2. Year of ESRD Incidence or Transplantation 21.5 19.8 4.1 2.0 1999 annual report of the US Renal Data System Deaths/100 patient-years Adjusted 1st Year Patient Death Rates by Treatment Modality and Year of Incidence, 1986-96 Dialysis All ESRD Cadaveric Transplant Living Related Transplant
  • 3. 0.01 100 10 1 0.1 Annual mortality (%) 25–34 45–54 65–74  85 35–44 55–64 75–84 Age (years) Cardiovascular Mortality in the General Population and in Dialysis Patients General population Male Female Black White Dialysis population Male Female Black White
  • 4. NKF’s Clinical Practice Guidelines <ul><li>Evidence Based Review </li></ul><ul><li>Publication and Dissemination </li></ul><ul><li>Implementation </li></ul><ul><li>Reassess Impact </li></ul><ul><li>Update </li></ul>
  • 5. DOQI KDIGO K/DOQI Dialysis Anemia Access Nutrition (00) Dialysis (’01)* Anemia (’01)* Access(‘01)* CKD class. (’02) Bone/Mineral (’03) Lipids (’03) Htn (’04) CV (’05) Diabetes (’07) Hep C (’08) Bone/Mineral (’08) 1997 2005 *updates http://www.kidney.org/professionals/kdoqi 1999 http://www.kdigo.org/welcome.htm
  • 6. NKF-K/DOQI Definition of CKD <ul><li>Structural or functional abnormalities of the kidneys for &gt; 3 months, as manifested by either: </li></ul><ul><li>1. Kidney damage , with or without decreased GFR, as defined by </li></ul><ul><ul><ul><li>pathologic abnormalities </li></ul></ul></ul><ul><ul><ul><li>markers of kidney damage </li></ul></ul></ul><ul><ul><ul><ul><li>urinary abnormalities ( proteinuria ) </li></ul></ul></ul></ul><ul><ul><ul><ul><li>blood abnormalities (renal tubular syndromes) </li></ul></ul></ul></ul><ul><ul><ul><ul><li>imaging abnormalities </li></ul></ul></ul></ul><ul><ul><ul><li>kidney transplantation </li></ul></ul></ul><ul><li>2. GFR &lt;60 ml/min/1.73 m 2 , with or without kidney damage </li></ul>
  • 7. KDOQI: CKD Staging &lt; 15 (or dialysis) Kidney failure 5 15-29 Severe  GFR 4 30-59 Moderate  GFR 3 60-89 Kidney damage with mild  GFR 2  90 Kidney damage with normal or  GFR 1 GFR (ml/min/1.73 m 2 ) Description Stage
  • 8. CKD is a Public Health Problem <ul><li>CKD is common </li></ul><ul><li>CKD is harmful </li></ul><ul><li>We have treatment </li></ul>
  • 9. CKD death Complications Screening for CKD risk factors: diabetes hypertension age &gt;60 family history US ethnic minorities CKD risk reduction; Screening for CKD Diagnosis &amp; treatment; Treat comorbid conditions; Slow progression Estimate progression; Treat complications; Prepare for replacement Replacement by dialysis &amp; transplant Normal Increased risk Kidney failure Damage  GFR Conceptual Model for CKD 11.3 m 5.6% 7.7 m 7.7 m 3.8% 0.3 m 0.2%
  • 10. &gt;4.6
  • 11. K/DOQI Clinical Practice Guidelines on Bone Metabolism and Disease in Chronic Kidney Disease Published October 2003
  • 12. KDOQI Clinical Practice Guidelines for Bone Metabolism and Disease in Chronic Kidney Disease <ul><li>Chair: Vice-Chair: </li></ul><ul><li>Shaul G. Massry, MD Jack W. Coburn, MD </li></ul><ul><li>KECK School of Medicine VA Greater Los Angeles </li></ul><ul><li>Work Group Members: </li></ul><ul><li>Glenn M. Chertow, MD, MPH James T. McCarthy, MD </li></ul><ul><li>University of California, San Francisco Mayo Clinic </li></ul><ul><li>Keith Hruska, MD Sharon Moe, MD </li></ul><ul><li>Barnes Jewish Hospital Indiana University </li></ul><ul><li>Craig Langman, MD Isidro B. Salusky, MD </li></ul><ul><li>Children’s Memorial Hospital UCLA School of Medicine </li></ul><ul><li>Hartmut Malluche, MD Donald J. Sherrard, MD </li></ul><ul><li>University of Kentucky VA Puget Sound </li></ul><ul><li>Kevin Martin, MD, BCh Miroslaw Smogorzewski, MD </li></ul><ul><li>St. Louis University University of Southern California </li></ul><ul><li>Linda M. McCann, RD, CSR, LD Kline Bolton, MD </li></ul><ul><li>Satellite Dialysis Centers RPA Liaison </li></ul>
  • 13. K/DOQI™ Clinical Practice Guidelines on Bone Metabolism Target Levels *Evidence 35 - 70 “ Normal” 2.7 - 4.6 CKD Stage 3 150 - 300* 70 - 110 Intact PTH (pg/mL) 8.4 - 9.5; Hypercalcemia = &gt;10.2 “ Normal” Ca (mg/dL) 3.5 - 5.5* 2.7 - 4.6 P (mg/dL) CKD Stage 5 (on dialysis) CKD Stage 4
  • 14. Treatment Recommendations (Stages 3 &amp; 4) <ul><li>Decrease total body phosphorus burden by dietary restriction and phosphorus binder therapy- 2.7- 4.6 mg/dL; begin when EITHER elevated serum phosphorus OR elevated serum PTH </li></ul><ul><li>Treat elevated PTH with active oral vitamin D sterol to target of 35-70 (CKD 3) or 70-110 (CKD 4) pg/mL by intact assay </li></ul><ul><li>Normalize serum calcium </li></ul>
  • 15. <ul><li>Normalize serum phosphorus by diet and phosphorus binder therapy- 3.5-5.5 mg/dL (1.13 -1.78 mmol/L); limit elemental calcium intake from binders to 1500 mg/day </li></ul><ul><li>Treat elevated PTH with active vitamin D sterol to target of 150-300 pg/mL (16-32 pmol/L) by intact assay </li></ul><ul><li>Normalize serum calcium- ideally 8.4 -9.5 mg/dL (2.10-2.38 mmol/L), and always &lt; 10.2 mg/dL (2.55 mmol/L); Ca X P &lt; 55 mg 2 /dL 2 </li></ul>Treatment Recommendations Stage 5 (dialysis)
  • 16. Abnormal bone Age Oxidation (OxLDL) Diabetes HTN Advanced glycation end-products Smoking Genetics Dyslipidemia Carbonyl stress Low fetuin-A Traditional Risk Factors Non-traditional Risk Factors Elevated IL-1, Il-6, TNF  Abnormal mineral metabolism Fractures Cardiovascular disease in CKD Homocysteine
  • 17. Classification Issues in Bone and Mineral Disorders <ul><li>The term renal osteodystrophy is used to describe different entities </li></ul><ul><li>The predominant use is to describe a disorder of bone remodeling. However this does not take into account new data that there is increased morbidity/mortality of abnormal serum biochemistries (i.e. phosphorus), nor increased awareness of vascular disease related to bone and mineral disorders in CKD patients. </li></ul>
  • 18. Definition, Evaluation and Classification of Renal Osteodystrophy: A position statement from Kidney Disease Improving Global Outcomes (KDIGO) April, 2006
  • 19. Standardization of Terms <ul><li>The term renal osteodystrophy (ROD) should be used exclusively to define the bone pathology associated with CKD. </li></ul><ul><li>The clinical, biochemical, and imaging abnormalities should be defined more broadly as a clinical entity or syndrome called Chronic Kidney Disease-Mineral and Bone Disorder (CKD-MBD) . </li></ul>
  • 20. Definition of CKD-MBD <ul><li>A systemic disorder of mineral and bone metabolism due to CKD manifested by either one or a combination of the following: </li></ul><ul><ul><li>Abnormalities of calcium, phosphorus, PTH, or vitamin D metabolism </li></ul></ul><ul><ul><li>Abnormalities in bone turnover, mineralization, volume, linear growth, or strength </li></ul></ul><ul><ul><li>Vascular or other soft tissue calcification </li></ul></ul>Moe et al Kidney International June 2006
  • 21. Kidney International June 2006 * L = laboratory abnormalities (of calcium, phosphorus, PTH, alkaline phosphatase or vitamin D metabolism); B = bone disease (abnormalities in bone turnover, mineralization, volume, linear growth, or strength); C = calcification of vascular or other soft tissue. + + + LBC + - + LC - + + LB - - + L Calcification of Vascular or Other Soft Tissue Bone Disease Laboratory Abnormalities Type* A Framework for Classification of CKD-MBD
  • 22. www.kdigo.org
  • 23. Summary <ul><li>CKD is defined using eGFR and classified into 5 stages </li></ul><ul><li>This classification can help predict clinical outcomes </li></ul><ul><li>Early detection and treatment can improve patient outcomes </li></ul><ul><li>There is a link between CVD and bone and mineral disease in CKD </li></ul><ul><li>New CKD-MBD classification will form the basis for </li></ul><ul><li>updated, international clinical practice guidelines </li></ul>
  • 24. Population Attributable Risk of All Cause Mortality in CKD 5D <ul><li>17.5% Mineral metabolism abnormalities (Phosphorus &gt; 5.0 mg/dl, Calcium &gt; 10 mg/dl, intact PTH &gt; 600 pg/ml) </li></ul><ul><li>11.3% Anemia (hgb &lt; 11 g/dl) </li></ul><ul><li>5.1% Inefficient Dialysis (URR &lt; 65%) </li></ul><ul><li>Corollary: We should be able to significantly improve mortality of CKD patients by improving control of mineral metabolism </li></ul>Block et al JASN 2004

×