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KDIGO CKD 2012

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KDIGO CKD 2012

  1. 1. SUMANEE PRAKOBSUK 24 Sep 2013
  2. 2. • Chapter 1: Definition and classification of CKD • Chapter 2: Definition, identification, and prediction of CKD progression • Chapter 3: Management of progression and complications of CKD • Chapter 4: Other complications of CKD: CVD, medication dosage, patient safety, infections, hospitalizations, and caveats for investigating complications of CKD • Chapter 5: Referral to specialists and models of care
  3. 3. Conceptual model of CKD
  4. 4. • CKD: What’s NEW? •New CKD KDIGO Proposed Classification •New CKD Definition •New uACR •New eGFR Formula •Prevention & Treatment: Who & How? •How to assess CKD Progression?
  5. 5. CKD is defined as abnormalities of kidney structure or function, present for > 3 months, with implications for health CKD DEFINITION
  6. 6. STAGING OF CKD
  7. 7. Kidney Int 2011; 80: 17-28
  8. 8. Summary of categorical meta-analysis (adjusted RRs) for general population cohorts with ACR. Kidney Int 2011; 80: 17-28
  9. 9. Summary of categorical meta-analysis (adjusted RRs) for general population cohorts with ACR. Kidney Int 2011; 80: 17-28
  10. 10. Classification of CKD based on presence or absence of systemic disease and location within the kidney of pathologicanatomic findings
  11. 11. GFR categories in CKD
  12. 12. Albuminuria categories in CKD
  13. 13. Relationship among categories for albuminuria and proteinuria
  14. 14. CGA staging of CKD: examples of nomenclature
  15. 15. Evaluation of GFR • We recommend using serum creatinine and a GFR estimating equation for initial assessment.(1A) • We suggest using additional tests (such as cystatin C or a clearance measurement) for confirmatory testing in specific circumstances when eGFR based on serum creatinine is less accurate. (2B) • Report eGFRcreat in adults using the 2009 CKD-EPI creatinine equation.
  16. 16. Sources of error in GFR estimating using creatinine
  17. 17. Performance of the CKD-EPI and MDRD Study equations in estimating measured GFR in the external validation data set Ann Intern Med 2009; 150(9): 604-612. CKD-EPI MDRD
  18. 18. Meta-analysis of NRI for all-cause mortality, CVD mortality, and ESRD JAMA 2012; 307(18): 1941-1951
  19. 19. N Engl J Med 2012;367:20-9.
  20. 20. N Engl J Med 2013;369:932-43.
  21. 21. Sources of error in GFR estimating using cystatin C
  22. 22. Evaluation of albuminuria
  23. 23. Factors affecting urinary ACR
  24. 24. DEFINITION AND IDENTIFICATION OF CKD PROGRESSION
  25. 25. PREDICTORS OF PROGRESSION
  26. 26. Management of progression and complications of CKD • PREVENTION OF CKD PROGRESSION – BP and RAAS interruption – Glycemic control – Hyperuricemia – Protein intake – Salt intake • COMPLICATIONS ASSOCIATED WITH LOSS OF KIDNEY FUNCTION – Anemia – CKD-MBD – Acidosis
  27. 27. Management of progression and complications of CKD • PREVENTION OF CKD PROGRESSION – BP and RAAS interruption – Glycemic control – Hyperuricemia – Protein intake – Salt intake • COMPLICATIONS ASSOCIATED WITH LOSS OF KIDNEY FUNCTION – Anemia – CKD-MBD – Acidosis
  28. 28. Clinical Practice Guideline of HT in CKD • 2004 KDOQI (Kidney disease Outcomes Quality Initiative) Clinical Practice Guidelines on Hypertension and Antihypertensive Agents in Chronic Kidney Disease • KDIGO (The Kidney Disease Improving Global Outcome) : Management of Blood Pressure in Chronis Kidney Disease ; December 2012
  29. 29. KDIGO Clinical Practice Guideline for the Management of Blood Pressure in Chronic Kidney Disease 2012 Non-diabetic Diabetic BP goal AER <30 ≤ 140/90 (1B) ≤ 140/90 (1B) AER >30 ≤ 130/80 (2D,C) ≤ 130/80 (2D) Medication AER 30-300 ARB/ACEI (2B) ACEI/ARB (2D) AER>300 ARB/ACEI (1B) ACEI/ARB (1B)
  30. 30. Lawrence J.Appel ; NEJM 2010 363:918-29.
  31. 31. AASK : Conclusion • RCT in black with CKD • N = 1094 • Randomly assigned : ramipril , metoprolol or amlodipine • Target mABP intensive arm : 92 mmHg • Target mABP standard arm : 102-107 mmHg Result • Primary endpoint: No difference in rate of GFR decline • ACEI may be more effective than BB in slowing GFR decline • Subgroup – UPCR ≤ 0.22: No effect – UPCR>0.22: Intensive BP retard CKD progression (a doubling sCr,ESRD or death) Lawrence J.Appel ; NEJM 2010 363:918-29.
  32. 32. AASK Lawrence J.Appel ; NEJM 2010 363:918-29.
  33. 33. study/year outcome intervention control HOPE 2001 MI, stroke in CKD Ramipril placebo HOPE 2003 Dialysis, renal insufficiency Ramipril placebo PREVEND 2004 CV events Fosinopril placebo ALLHAT 2006 Renal failure &CAD with CKD In DM /non DM pt lisinopril Chlorthalidone PEACE 2006,2007 CV mortality in CKD trandolapril placebo TRANSCEN 2009 Dialysis/sCr doubling telmisartan placebo Val-HeFT 2009 Death valsartan Placebo
  34. 34. William C.Cushman;NEJM 2010;362:1575-85
  35. 35. Action to Control Cardiovascular Risk in Diabetes : ACCORD study • 10251 patients from 77 centers US. And Canada • 4377 patients in ACCORD BP trial • DM type II with HbA1C ≥7.5% • ≥40 with CVD • ≥55 with – Evidence of atherosclerosis ,albuminuria or LVH – 2 additional CV risk factors • Assigned to either – Intensive BP control (systolic BP<120mmHg) – Conventional BP control (systolic BP<140 mmHg) William C.Cushman;NEJM 2010;362:1575-85
  36. 36. William C.Cushman;NEJM 2010;362:1575-85
  37. 37. William C.Cushman;NEJM 2010;362:1575-85
  38. 38. ACCORD study : conclusions Intensive BP control • Did not significantly reduce primary CV-event • Some possible harm – Hypotension – Arrhythmia or bradycardia – HyperK – Elevate SCr William C.Cushman;NEJM 2010;362:1575-85
  39. 39. • Rationale – DM II with microalbuminuria increased risk kidney failure and CV events – ACEI ,ARB reduce albuminuria in DM II with microabluminia
  40. 40. • Ratinale – Pt with DM and high levels of urine albumin high risk of adverse CV and kidney outcomes – Strong evidence from RCTs : ACEI &ARB protect against kidney failure and reduce urine albumin level
  41. 41. The Ongoing Telmisartan Alone and in combinaion with Ramipril Global Endpoint Trial ONTARGET • Multicenter RCT • 2001-2007 • Age >55 yrs with – Atherosclerotic disease – DM with end organ damage • 25,630 were randomized to either – Tarmisartan 80 mg/day – Ramipril 10 mg/day – Tarmisartan 80mg+ramipril 10mg/day
  42. 42. The ONTARGET study : conclusions • Combination  no benefit in primary outcome compare to Ramipril • Combination  Worse kidney outcome • Combination  Significantly increase – Risk of hypotension – Syncope – Renal dysfuntion( requiring acute dialysis) – Hyperkalemia Johannes F E Mann;Lancet 2008;372:547-53
  43. 43. Add on aliskiren 300mg More hyperK in combine aliskiren group
  44. 44. Management of progression and complications of CKD • PREVENTION OF CKD PROGRESSION – BP and RAAS interruption – Glycemic control – Hyperuricemia – Protein intake – Salt intake • COMPLICATIONS ASSOCIATED WITH LOSS OF KIDNEY FUNCTION – Anemia – CKD-MBD – Acidosis
  45. 45. Management of progression and complications of CKD • PREVENTION OF CKD PROGRESSION – BP and RAAS interruption – Glycemic control – Hyperuricemia – Protein intake – Salt intake • COMPLICATIONS ASSOCIATED WITH LOSS OF KIDNEY FUNCTION – Anemia – CKD-MBD – Acidosis
  46. 46. Glycemic control
  47. 47. UKPDS( DM type II) extended follow up
  48. 48. DCCT/EDIC (DM type I) • Additional 11 years • A1C: 8% (equally) • Result: Intensive therapy  Decrease – Microalbuminuria – Macroalbuminuria – Doubling SCr  No – SCr > 2  Yes – HT – 42% relative reduction in CV events – Decrease mortality
  49. 49. Guideline
  50. 50. KDOQI CLINICAL PRACTICE GUIDELINE FOR DIABETES AND CKD: 2012 UPDATE
  51. 51. KDIGO CKD 2012 Kidney International Supplements (2013) 3, v
  52. 52. Management of progression and complications of CKD • PREVENTION OF CKD PROGRESSION – BP and RAAS interruption – Glycemic control – Hyperuricemia – Protein intake – Salt intake • COMPLICATIONS ASSOCIATED WITH LOSS OF KIDNEY FUNCTION – Anemia – CKD-MBD – Acidosis
  53. 53. Management of progression and complications of CKD • PREVENTION OF CKD PROGRESSION – BP and RAAS interruption – Glycemic control – Hyperuricemia – Protein intake – Salt intake • COMPLICATIONS ASSOCIATED WITH LOSS OF KIDNEY FUNCTION – Anemia – CKD-MBD – Acidosis
  54. 54. Serum Uric acid • Elevated SUA (>7 in men, >6 in woman) • Observational data: Elevate SUA – Progression of CKD – Increase All cause mortality – Increase CV mortality – CKD may be improved by specific uric acid lowering therapy. • RCT design • Small study show benefit in: – Reduced LV mass1 – Improved endothelial function1 – Decrease CV events2 – Decrease hospitalization2 1 Kanbay M, Clin J Am Soc Nephrol 2011; 6: 1887–1894. 2 Goicoechea M, Clin J Am Soc Nephrol 5: 1388–1393, 2010
  55. 55. KDIGO 2012 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease
  56. 56. Protein intake • We suggest lowering protein intake to 0.8 g/kg/day in adults with diabetes (2C) or without diabetes (2B) and GFR <30 ml/min/ 1.73 m2 (GFR categories G4-G5), with appropriate education. • We suggest avoiding high protein intake >1.3 g/kg/day in adults with CKD at risk of progression. (2C)
  57. 57. Salt intake • We recommend lowering salt intake to < 90 mmol(<2 g) per day of sodium (corresponding to 5 g ofsodium chloride) in adults. (1C)
  58. 58. Management of progression and complications of CKD • PREVENTION OF CKD PROGRESSION – BP and RAAS interruption – Glycemic control – Hyperuricemia – Protein intake – Salt intake • COMPLICATIONS ASSOCIATED WITH LOSS OF KIDNEY FUNCTION – Anemia – CKD-MBD – Acidosis
  59. 59. Management of progression and complications of CKD • PREVENTION OF CKD PROGRESSION – BP and RAAS interruption – Glycemic control – Hyperuricemia – Protein intake – Salt intake • COMPLICATIONS ASSOCIATED WITH LOSS OF KIDNEY FUNCTION – Anemia – CKD-MBD – Acidosis
  60. 60. Anemia in CKD patients Semin Nephrol 26:261-268 RAS blockade
  61. 61. AJKD 2006;47(5):S81-85.
  62. 62. • 1.2.1: Diagnose anemia in adults and children >15 years with CKD when the Hb concentration is <13.0 g/dl in males <12.0 g/dl in females. (Not Graded) Investigation of anemia 1.3: In patients with CKD and anemia (regardless of age and CKD stage), include the following tests in initial evaluation of the anemia (Not Graded): •Complete blood count (CBC), which should include Hb concentration, red cell indices, white blood cell count and differential, and platelet count • Absolute reticulocyte count • Serum ferritin level • Serum transferrin saturation (TSAT) •Serum vitamin B12 and folate levels
  63. 63. USE OF IRON TO TREAT ANEMIA IN CKD 2.1.1: When prescribing iron therapy, balance the potential benefits of avoiding or minimizing blood transfusions, ESA therapy, and anemia related symptoms against the risks of harm in individual patients (e.g., anaphylactoid and other acute reactions, unknown long-term risks). (Not Graded)
  64. 64. 2006
  65. 65. 2012 2.1.2: For adult CKD patients with anemia not on iron or ESA therapy we suggest a trial of IV iron (or in CKD ND patients alternatively a 1–3 month trial of oral iron therapy) if (2C): • an increase in Hb concentration without starting ESA treatment is desired* and • TSAT is <30% and ferritin is <500 ng/ml (500 mg/l)
  66. 66. 2012 2.1.3: For adult CKD patients on ESA therapy who are not receiving iron supplementation, we suggest a trial of IV iron (or in CKD ND patients alternatively a 1–3 month trial of oral iron therapy) if (2C): • an increase in Hb concentration** or a decrease in ESA dose is desired*** and • TSAT is <30% and ferritin is <500 ng/ml (500 mg/l)
  67. 67. ESA INITIATION • 3.1: Address all correctable causes of anemia (including iron deficiency and inflammatory states) prior to initiation of ESA therapy. (Not Graded) • 3.2: In initiating and maintaining ESA therapy, we recommend balancing the potential benefits of reducing blood transfusions and anemia-related symptoms against the risks of harm in individual patients (e.g., stroke, vascular access loss, hypertension). (1B)
  68. 68. • 3.3: We recommend using ESA therapy with great caution, if at all, in CKD patients with active malignancy—in particular when cure is the anticipated outcome—(1B), a history of stroke (1B), or a history of malignancy (2C).
  69. 69. 2.1.2 In the opinion of the Work Group, in dialysis and nondialysis patients with CKD receiving ESA therapy, the selected Hb target should generally be in the range of 11.0 to 12.0 g/dL. 2.1.3 In dialysis and nondialysis patients with CKD receiving ESA therapy, the Hb target should not be greater than 13.0 g/dL 2006
  70. 70. • 3.4.1: For adult CKD ND patients with Hb concentration >10.0 g/dl (>100 g/l), we suggest that ESA therapy not be initiated. (2D) • 3.4.2: For adult CKD ND patients with Hb concentration <10.0 g/dl (<100 g/l) we suggest that the decision whether to initiate ESA therapy be individualized based on – the rate of fall of Hb concentration – prior response to iron therapy, – the risk of needing a transfusion, the risks related to ESA therapy and the presence of symptoms attributable to anemia. (2C) ESA INITIATION : CKD ND
  71. 71. ESA INITIATION : CKD 5D • 3.4.3: For adult CKD 5D patients, we suggest that ESA therapy be used to avoid having the Hb concentration fall below 9.0 g/dl (90 g/l) by starting ESA therapy when the hemoglobin is between 9.0–10.0 g/dl (90–100 g/l). (2B) • 3.4.4: Individualization of therapy is reasonable as some patients may have improvements in quality of life at higher Hb concentration and ESA therapy may be started above 10.0 g/dl (100 g/l). (Not Graded)
  72. 72. ESA MAINTENANCE THERAPY • 3.5.1: In general, we suggest that ESAs not be used to maintain Hb concentration above 11.5 g/dl (115 g/l) in adult patients with CKD. (2C) • 3.5.2: Individualization of therapy will be necessary as some patients may have improvements in quality of life at Hb concentration above 11.5 g/dl (115 g/l) and will be prepared to accept the risks. (Not Graded) • 3.6: In all adult patients, we recommend that ESAs not be used to intentionally increase the Hb concentration above 13 g/dl (130 g/l). (1A)
  73. 73. MEDICATION MANAGEMENT AND PATIENT SAFETY IN CKD • We recommend that prescribers should take GFR into account when drug dosing. (1A) • We recommend that adults with CKD seek medical or pharmacist advice before using over- the-counter medicines or nutritional protein supplements. (1B) • We recommend not using herbal remedies in people with CKD. (1B)
  74. 74. MEDICATION MANAGEMENT AND PATIENT SAFETY IN CKD • We recommend that metformin be continued in people with GFR >45 ml/min/1.73 m2 (GFR categories G1-G3a); • its use should be reviewed in those with GFR 30– 44 ml/min/1.73 m2 (GFR category G3b); • it should be discontinued in people with GFR <30 ml/min/1.73 m2 (GFR categories G4-G5). (1C)
  75. 75. IMAGING STUDIES : Radiocontrast • We recommend that all people with GFR <60 ml/min/1.73 m2 undergoing elective investigation involving the IV iodinated radiocontrast media should be managed according to the KDIGO Clinical Practice Guideline for AKI including: – Avoidance of high osmolar agents (1B); – Use of lowest possible radiocontrast dose (Not Graded); – Withdrawal of potentially nephrotoxic agents before and after the procedure (1C); – Adequate hydration with saline before, during, and after the procedure (1A); – Measurement of GFR 48–96 hours after the procedure (1C).
  76. 76. IMAGING STUDIES : Gadolinium-based contrast media Nephrogenic systemic fibrosis
  77. 77. • We recommend not using gadolinium- containing contrast media in people with GFR <15 ml/min/1.73 m2 (GFR category G5) unless there is no alternative appropriate test. (1B) • We suggest that people with a GFR <30 ml/min/1.73 m2 (GFR categories G4-G5) who require gadolinium containing contrast media are preferentially offered a macrocyclic chelate preparation. IMAGING STUDIES : Gadolinium-based contrast media
  78. 78. Bowel preparation • We recommend not to use oral phosphate- containing bowel preparations in people with a GFR < 60 ml/min/1.73 m2 (GFR categories G3a-G5) or in those known to be at risk of phosphate nephropathy. (1A)
  79. 79. Regimen : 45 ml two dose taken 10-12 hrs apart ,the evening before and the morning of colonoscopy Each 45 ml contain 5.8 g of elemental phosphorus Ramathibodi SWIFF solution Kidney International (2009) 76,1027-103
  80. 80. REFERRAL TO SPECIALIST SERVICES
  81. 81. TIMING THE INITIATION OF RRT • We suggest that dialysis be initiated when one or more of the following are present – symptoms or signs attributable to kidney failure (serositis, acid-base or electrolyte abnormalities, pruritus) – inability to control volume status or blood pressure – a progressive deterioration in nutritional status refractory to dietary intervention – cognitive impairment. • This often but not invariably occurs in the GFR range between 5 and 10 ml/min/1.73 m2. (2B)
  82. 82. TIMING THE INITIATION OF RRT • Living donor preemptive renal transplantation in adults should be considered when the GFR is <20 ml/min/1.73 m2, and there is evidence of progressive and irreversible CKD over the preceding 6–12 months.(Not Graded)
  83. 83. IDEAL Study

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