Myths in Nephrology 1

Sheffield Kidney Institute
Myths and Legends in Nephrology
Jordanian Society of Nephrology 2016
Prof Meguid El Nahas, MD, PhD, FRCP
Professor of Nephrology & Chairman
Global Kidney Academy
Sheffield, UK

In nephrology

CKD Prevalence is rising
KDIGO CKD Classification is useful
eGFR is useful
Intensive BP reduction slows Progression
Proteinuria reduction slows Progression
ACE inhibition Slows Progression

The Nephrology Herd Mentality

Critical Thinking

Critical Thinking
A Good Nephrologist

eGFR is useful
Maximum BP reduction slows Progression
Proteinuria reduction slows Progression
ACE inhibition Slows Progression

eGFR is useful

CKD Prevalence is rising in Community

An increasing number of people are
suffering from CKD…

What is CKD Prevalence?
a. 5%
b. 10%
c. 20%
d. 40%

What is CKD Prevalence
in the over 65?
a. 5%
b. 10%
c. 20%
d. 40%

CKD Prevalence in UK

UK CKD
eGFRKDOQI
Classification
CKD Prevalence in UK

Prevalence of CKD
NHANESIII
0%
5%
10%
15%
20%
25%
30%
35%
40%
Prevalenc
e (%)
20-39 40-59 60-69 70+
Age Group (years)
<2%
>30%

McCullough et al, 2012

Population Profile

eGFR Decline with Age

Population Profile
GFR = 120 GFR = 100 GFR = 90

IS AGEING A DISEASE?

MEDICALISATION OF NORMALITY…!!!

Medicalisation of Normality
cCKD in the Aged

eGFR & RAAS Prescribing
Jain et al, 2012

DO YOU THINK THERE IS AN EPIDEMIC OF CKD?

DO YOU THINK THERE IS AN EPIDEMIC OF CKD?
NO, There is an Epidemic of Ageing!

People
>60!
5%
10
%
15%
25%

C-K-D
CVD
NCD

Is CKD rising in the Community

Deviation from Normality
3 Moderate renal insufficiency 59-30
4 Severe renal insufficiency 29-15
5 Kidney Failure/ERF/ESRD <15

Lancet 2010

KDIGO 2010
Lancet 2010

KDIGO 2012
Deviation from Normality + Risk Stratification

Deviation from Normality <60 Years
60
120

Deviation from Normality >60 Years
90

A
G
E
M
O
R
T
A
L
I
T
Y

Deviation from Normality >60 Years
45
90

CKD Classification <60years
Stage Description GFR
1 Kidney damage/normal GFR >90ml/min
2 Mild renal insufficiency 89-60
3 Moderate renal insufficiency
A 59-45*
B 44-30 (p)
• * * = not applicable >60 unless proteinuria (p) present
2014 Revised Classification

2014 Revised Classification
CKD Classification>60
Stage Description GFR
1 Kidney damage/normal GFR >90ml/min*
2 Mild renal insufficiency 89-45*

CKD3a
US = 5m
China: 20m
Age Related “CKD3a”

CKD3a
US = 5m
China: 20m
3.6 1

eGFR is useful

eGFR is useful
Classification
Early Detection
Early Treatment
Risk Stratification
Progression monitoring
Management

Sheffield Kidney Institute 19
LDL-cholesterol (mg/dl) 137.0 (41.6)
Table 2 – eGFR levels and CKD by estimating method, in the overall sample and by age
strata.
Method
Overall sample age <65 age 65+
eGFR
ml/min/1.73m2
CKD:
eGFR <60
ml/min/1.73m2
No. of
individuals with
eGFR <30
ml/min/1.73m2
eGFR ml/min/1.73m2
mean (SD)
mean (SD) N
Prevalence
% (95%CI)
MDRD-4 84.7 (16.2) 69 5.8 (4.5-7.2) 1 86.8 (15.3) 74.3 (16.3)
MDRD-6 87.0 (16.1) 46 3.8 (2.8-5.1) 1 89.6 (15.0) 74.4 (15.1)
CKD-EPI 92.8 (16.8) 43 3.6 (2.6-4.8) 0 96.6 (14.9) 74.4 (13.3)
Virga 99.2 (20.9) 21 1.8 (1.1-2.7) 0 102.7 (19.7) 82.3 (18.2)
Cystatin C 103.9 (24.6) 52 4.3 (3.3-5.6) 2 110.0 (20.7) 74.6 (20.2)
Cystatin / Creatinine 98.6 (19.8) 33 2.8 (1.9-3.8) 1 103.1 (17.1) 76.9 (17.4)
Pattaro et al, 2013
CKD Classification

Spanaus et al, MMKD 2010
CKD Detection

KDIGO 2012
ESRD Risk: An Early Detection
sCr

Mantra: “Early Detection…Better Prevention…”
O’Hare et al, 2013

fils, M., Nivez, M. P., Isaac, R., Mayaud, C., Sraer,
olec. Med. 1975, 49, 301.
. P., Piamba, G., Fillastre, J. P., Ardaillou, R. Nephro-
.
, J. A., Earnshaw, M., Russell, R. G. G., Woods, C. G.
Transpl. Ass. (in the press).
nshaw, M., Heynen, G., Ledmgham, J. G. G., Oliver,
Russell, R. G. G., Woods, C. G. ibid. (in the press).
rson, R. G., Heynen, G., Ledingham, J. G. G., Russell,
R., Walton, R. J. Archs dis. Childh, (in the press).
on, J. L. E. Israel. J. med. Sci. 1971, 7, 488.
ith, R., Ledingham, J. G. G., Oliver, D. O. Proc. eur.
ss. 1971, 8, 122.
nenko, P., Meyner, A., Vallee, G., Beaugas, C. J. clin. In-
345.
53226, U.S.A.
In 31 of 34 patients with chronic renal
insufficiency caused by various diseases,
um-creatinine concentration declined
inine concentration rose from a mean of
ot;8 mg/dl over an average of 71 months.
indicate that in most cases reciprocal
e declines linearly with time as chronic
gresses. Analysis of this relation in indi-
gives an estimate of the progression of
help to determine the effects of therapy,
ed to predict when dialysis will become
Introduction
enal failure develops, serum-creatinine
easingly more rapidly. (This prediction
e well known inverse relation between
nd serum concentration of substances
-rate is constant.l If this were the case,
m-creatinine might fall linearly with
ned this hypothesis in patients who had
ilure with various causes.
Methods
ecords of all patients with chronic renal fail-
n followed in a renal clinic for at least a year
here were 34 patients in whom 7 or more cre-
tions had been performed and in whom there
a threefold increase in creatinine concentra-
r of determinations over a period of at least
sen as sufficient to determine whether there
trend in serum-creatinine with time in indi-
he reciprocal of serum-creatinine concentra-
at the Annual Meeting of the American Federation
h, Atlantic City, N.J., May 2-5, 1976, and pub-
rm (Clin. Res. 1976, 24, 407).
accompanying table. The average of the correlation
coefficients was 0.954 (excluding the patients who had
a non-linear decline in reciprocal serum-creatinine). The
95% confidence limits of the slopes averaged 17.1% of
the individual slopes, with a range of 5.6 to 32.0%.
These limits indicate the smallest change in the rate of
progression that would be detectable by this method.
Discussion
These results indicate that in most patients reciprocal
serum-creatinine concentration declines linearly as
chronic renal failure progresses. There appear to be few
Composite plot of reciprocal serum-creatinine concentration (in
mg/dl) versus months of observation in 6 patients with
chronic renal failure.
Final value for reciprocal of serum-creatinine concentration is
shown for each patient. Ordinate has uniform divisions of 0.1 dl/mg.
Diagnoses in these patients are indicated.
CKD Progression
Mitch et al 1976
1:sCr

Prediction of CKD Progression

sCr >148umol/lGFR <54ml/min
sCR and GFR Prognostic value

Gaspari et al, 2012
eGFR v mGFR and CKD Progression

KDIGO 2010

Chang and Kramer, 2011

sCr = eGFR
eGFR = mGFR

Nephrology
Publications

Nephrologist
CKD
Proteinuria
ACEi
BP

ENES 2016
PRAGUE 5-6th MARCH, 2016
enquiries@globalkidneyacademy.co.uk

Myths in Nephrology 1

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