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1. Chronic Kidney Disease: A Silent Epidemic (Part 1) Naima Ogletree, MSN, APRN, BC Nephrology & Hypertension Henry Ford Health System

4. Physical Location of Human Kidney LEFT KIDNEY BLADDER URETER

5. Anatomy of the Kidney FIBROUS CAPSULE CORTEX PYRAMID PAPILA RENAL CALYX RENAL PELVIS RENAL ARTERY RENAL VEIN URETER

7. A MICROSCOPIC LOOK AT THE RENAL CORTEX GLOMERULUS

8. Glomerulus Anatomy

15. CKD: Care is Costly TH Hostetter, National Kidney Education Program, 2003. CKD Care $19.3 Billion/Yr Total NIH Budget $17.8 Billion/Yr CKD Accounts for 6% of Medicare Payments Lost Income for pts is $2 – 4 Billion/Yr

16. CKD: Prevalence by NHANES III 5.9 5.3 7.6 0.4 0.3 J Coresh, et al. Am J Kidney Dis. 2003;41(1):1 – 12

18. CKD: Prevalence by NHANES III CGM Jones, et al. Am J Kidney Dis. 1998;32:992 –999. J Coresh, et al. Am J Kidney Dis. 2003;41:1–12.

21. ESRD: Disease of the Elderly n =361,031 5961 55,105 125,280 148,508 26,177 United States Renal Data System (USRDS) 1997 Annual Data Report .

22. ESRD:  Risk by Ethnicity Racial Differences in ESRD in U.S. from 1990–1998 United States Renal Data System (USRDS) 2000 Annual Data Report • WWW.USRDS.ORG. reference * * * * P <0.0001 1.00 4.45 3.57 1.59 0 1 2 3 4 5 White Black Native Asian Odds Ratio

23. ESRD: Prevalence by Ethnicity Abbrev: NA, Native American; AA, African-American; C, Caucasian. n = 361,031 United States Renal Data System (USRDS) 1997 Annual Data Report .

24. ESRD: Incidence by Ethnicity Racial Differences in ESRD in U.S. from 1990–1998 United States Renal Data System (USRDS). 2000 Annual Data Report • WWW.USRDS.ORG.

25. ESRD:  Incidence and Prevalence US Renal Data System, 2000 Atlas of ESRD in the United States. Diabetes is the most common cause in Caucasians, Hispanics, Asians, and overall. Among African-Americans, hypertension is the most common cause of ESRD.

26. ESRD: Racial Distribution for Comorbidities in Dialysis (1999) § Diabetes mellitus as a primary diagnosis or contributing diagnosis. ‡ Diabetes mellitus that requires insulin treatment, which is a subset of the diabetes category. United States Renal Data System (USRDS) 2000 Annual Data Report • WWW.USRDS.ORG

27. Am J Kidney Dis. 2003 Nov;42(5):972-81 Inpatient Days among Elderly Medicare Pts with CKD in the United States. Overall Rates of Hospitalization

28. GFR and Hospitalization Go et al. New Engl J Med. 2004;351:1296-1305.

29. Change in FOCUS 2 3 4 CKD E S R D

32. CKD: Early CKD Treatment Preserves Kidney Function TH Hostetter, National Kidney Disease Education Program, 2003. GFR Time (yr.) 100 75 50 25 10 4 7 9 11

33. CKD Complications Evolution and Acceleration by Stage DM, ARF: CKD complications may occur earlier CKD Stage 1 2 3 4 Affected pts (%) 0 20 40 60 80 100 Hypertension Hyperparathyroidism Anemia (Hgb < 12 g/dl) Phosphorus > 4.5 mEq/L Fail quarter mile walk Hypoalbuminemia (Alb < 3.5 g/dl)

41. CKD: Evolution of GFR Estimating Methods A Akbari, et al. Arch Intern Med. 2003;163:356 – 360. S Klahr, et al. MDRD Study Group. N Engl J Med. 1994;330:877 – 884. BUN S Cr Highly Insensitive For CKD Detection 24-h CrCl Overestimates GFR Unnecessary test Cockroft Gault Eqn Estimates raw CrCl, not GFR MDRD GFR Eqn Validated Best choice

47. NKF CKD Stages 1–5 Kidney/Dialysis Outcomes Initiative. Am J Kidney Dis. 2002;39:S1 – S266.

52. CKD: Survey of PCPs

53. CKD: Delayed Referral to Nephrologist A Stack. Am J Kidney Dis. 2003;41:310 –318.

55. CKD: C onsequences of Delayed Referral A Stack. Am J Kidney Dis. 2003;41:310 –318. Late referral means <4 mo between time of initial Nephrology consultation and dialysis. AVF, arteriovenous fistula; AVG, arteriovenous graft.

56. CKD: Delayed Referral Results in Higher Medical Costs in Early ESRD Source: BA Boissonault for the Niagara Health Quality Coalition, 2003.

57. Advanced CKD Substantially Impairs Quality of Life Klang et al. Quality of Life Research . 1996;5:109-116. Sickness Impact Profile (SIP) 0 5 10 15 20 25 Work Eating Recreation/pastime Home management Sleep/rest Psychosocial Physical Overall SIP SIP Score CRI pts (N = 38) Reference group Note: Higher scores indicate poorer QOL.

62. Acute Renal Failure: NSAID-Induced Afferent Arteriolar Constriction P eff P eff VA Valentini, et al. Arch Intern Med. 1991;151:2367 – 2372. R AA , afferent arteriolar resistance. P aff NSAID P aff  P GC   R AA NORMAL P GC

68. Recommendations for Common Interventions Used to Prevent Contrast-medium-induced Nephropathy Recent high-dose study shows benefit in angioplasty Inconsistent trial results, optimal dose not clear Multiple RCTs Meta-analyses 600 mg po q12 h × 4, starting before contrast delivery N -acetyl cysteine Not generally recommended, need further trials to confirm efficacy Methodologic flaws in trial Single RCT showed lower risk of 25% increase of S Cr v 0.9% saline at same rate/duration 154 mmol/L at 3 cc/kg/h before contrast, then 1 mL/kg/h for 6 hours after IV Sodium Bicarbonate Low osmolality medium Lowest contrast volume Isosmolar contrast may be less risky in high risk pts, more data required Meta-analysis of many RCTs comparing low to high Low osmolality, lowest dose possible Contrast Medium RECOMMENDED Avoid ECF volume depletion Optimize HF 125 mL/h NSS Optimal duration of iv therapy not fully established by existing trials Small randomized trials: iv saline vs oral fluids; shorter regimens of iv fluids; and 0.45% saline 0.9% saline at 1 mL/kg/h for 24 h, start 12 h pre-contrast delivery IV saline therapy

73. NKF Guidelines address domains of CKD care

74. NKF Guidelines address domains of CKD care Periodic eGFR

75. Decrease CV Disease Risk Factors

76. CKD: CVD Prevention Strategies — Level of Evidence Large RCTs that involve CV risk prevention strategies in CKD have not been performed. Smoking (B) Folic acid (C) Aspirin Wt loss (B) Exercise (C) Lipid tx (B,C)

77. Major Cause of Death in CKD Cardiovascular Disease Shulman et al. Hypertension. 1998;13(supple 1):I-80 –I-93.

79. Cardiovascular Health Study: “Even Mildly Elevated S Cr Increases CV Disease (CVD) Risk.” Kidney/Dialysis Outcomes Initiative Clinical Practice Guidelines for Managing Dyslipidemias in Chronic Kidney Disease. Am J Kidney Dis. 2003;41(Suppl 3):S1 – S91.

80. CKD: CVD Comorbidities (1999) § Diabetes mellitus as a primary or contributing diagnosis. ‡ Diabetes mellitus that requires insulin treatment, which is a subset of the diabetes category.

81. CV Mortality in General Population (GP) & Dialysis pts by Ethnicity MJ Sarnak, AS Levey. Semin Dial. 1999;12:69 – 76.

84. Hypertension & CKD

85. Guideline: Hypertension 1.1 Antihypertensive therapy should be used in CKD to: 1.1.a. Lower blood pressure (A); 1.1.b. Reduce the risk of CVD, in pts with or without hypertension (B) 1.1.c. Slow progression of kidney disease, in pts with or without hypertension (A) 1.2 Modifications to antihypertensive therapy should be considered based on the level of proteinuria during treatment (C) 1.3 Antihypertensive therapy should be coordinated with other therapies for CKD as part of a multi-intervention strategy (A). 1.4 If there is a discrepancy between the treatment recommended to slow progression of CKD and to reduce the risk of CVD, individual decision-making should be based on risk stratification (C).

86. BP Control is Suboptimal † SBP <140 mmHg and DBP <90 mmHg NHLBI. JNC 7 Express. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure. 2003. 34 27 29 10 Control † 59 54 55 31 Treatment 70 68 73 51 Awareness 1999 – 2000 III: Phase 2 (1991 – 1994) III: Phase 1 (1988 – 1991) II (1976 – 1980) National Health and Nutrition Examination Surveys (Weighted %)

87. JNC 7 Reclassification of BP Based on Risk Source for JNC VI: Arch Intern Med . 1997;157:2413-2446. Adapted from Chobanian AV, et al. Hypertension. 2003;42:1206-1252. Optimal Normal <120/80 <120/80 Stage 1 Hypertension Stage 1 140-159/90-99 140-159/90-99 Normal Borderline Prehypertension 120-129/80-84 130-139/85-89 120-139/80-89 Stage 2 Stage 3 Stage 2 160-179/100-109 ≥ 180/110 ≥ 160/100 JNC VI BP (mm Hg) JNC 7 BP (mm Hg)

88. HTN Treatment by JNC 7 HTN w/ No Compelling Indications Stage 1 HTN (SBP 140-159 or DBP 90 – 99 mmHg) Thiazide diuretic for most Consider ACEI, ARB, β -blocker, CCB or combination Stage 2 HTN (SBP ≥ 160 or DBP ≥ 100 mmHg) 2-drug combo for most Usually thiazide + ACEI, ARB, β -blocker, or CCB Drug(s) for compelling indications Other BP drugs (thiazide + ACEI, ARB, β -blocker, CCB) as needed C (KD) ompelling Indications Chobanian AV, et al. The JNC 7 Report. JAMA. 2003;289:2560-2572. Compelling indications: CHF, post-MI, high risk of CAD, DM, CKD, stroke, migraine …

89. BP Targets in Diabetic and Nondiabetics with Kidney Disease Am J Kidney Dis, May (Suppl.), 2004 Type of Kidney Disease BP Target (mm Hg) Preferred Agents for CKD, with or without HTN Other Agents to Reduce CVD Risk and Reach BP Target Diabetic CKD SBP <125–130 DBP <75–80 ACE inhibitor or ARB Diuretic preferred, then BB or CCB Nondiabetic CKD UPC  200 mg/g Nondiabetic CKD UPC <200 mg/g None preferred Diuretic preferred, then ACEI/ARB, BB or CCB CKD in TX Recipient CCB, diuretic, BB, ACE inhibitor, ARB

90. HTN Treatment in CKD Diabetic or Nondiabetic

92. BP Control Prevents CKD Progression GFR Decline (mL/min/y) MAP (mm Hg) 95 98 101 107 104 110 113 116 119 r=0.69; P <.05 Untreated HTN 130/85 140/90 GFR, glomerular filtration rate; HTN, hypertension; MAP, mean arterial pressure. Adapted from Bakris GL et al. Am J Kidney Dis. 2000;36:646 - 661. 0 -2 -4 -6 -8 -10 -12 -14

94. Benefits of BP Therapy General Population CAD = coronary artery disease, PAD = peripheral artery disease; CHF = congestive heart failure. Adapted from: Kannel WB. JAMA. 1996;275:1571-1576. RR Ratios: 2.0 3.8 2.0 4.0 2.2 2.6 3.7 3.0 9.5 2.4 2.0 2.1 21.3 6.2 7.3 6.3 Biennial age-adjusted rate per 1000 pts at risk Normotensive Hypertensive 22.7 3.3 5.0 3.5 45.4 12.4 9.9 13.9 0 10 20 30 40 50 CAD Stroke PAD CHF Male 0 10 20 30 40 50 CAD Stroke PAD CHF Female

95. Hypertension and CKD Multiple Drugs Required UKPDS (<85 mm Hg, diastolic) MDRD (<92 mm Hg, MAP) HOT (<80 mm Hg, diastolic) AASK (<92 mm Hg, MAP) RENAAL (<140/90 mm Hg) IDNT (  135/85 mm Hg) 4 3 2 1 Type 2 DM Nondiabetic Kidney Disease DM Subgroup Analysis Type 2 DM Nephropathy Type 2 DM Nephropathy African Americans, No DM Number of BP Medications MAP = mean arterial pressure. Bakris G, et al. AJKD. 2000;36:646-661; Brenner BM, et al. NEJM. 2001;345:861-869. Lewis EJ, et al. NEJM. 2001;345:851-860.

97. Glycemic Control

101. Global Estimates and Projections for Incidence of Diabetes Mellitus A Amos, et al. Diabetes Medicine. 1997;14[Suppl 5]:S1-85. Type I Diabetes Type II Diabetes 0 50 100 150 200 250 In Millions 1997 2010 Year

102. NEW ESRD: Incidence from DM Centers for Disease Control Diabetes Surveillance, 1997.

104. “… it appears that there is an emerging pediatric epidemic of type 2 diabetes. If this epidemic cannot be averted, its full public health effect will be felt as affected children become adults and the long-term complications of diabetes develop.” New Engl J Med 2002:346(11)

105. ESRD: Etiology by 1° Diagnosis DM 50% HTN 27% GN 13% Other 10% United States Renal Data System (USRDS) 2000 Annual Data Report • WWW.USRDS.ORG.

106. First-year mortality rates, by CKD & diabetic status General Medicare patients age 67 & older; rates adjusted for age, gender, & race, & determined for the first year after the cohort-defining period. Reference population: 1999–2000 cohort.

107. Natural History of Diabetic Nephropathy

108. Glomerulus: Site of Hyperfiltration in Diabetes and Obesity

110. Diabetic Glomerulosclerosis

111. Glycemic Control Retards Progression of CKD Adapted with permission from Skyler JS. Endocrinol Metab Clin North Am. 1996;25:243 * Based on Diabetic Control and Complications Trial data 50% Reduction Retinopathy Nephropathy Neuropathy Microalbuminuria Relative Risk A 1 C (%) 15 13 11 9 7 5 3 1 6 7 8 9 10 11 12

113. Hb A 1c: Delay DN Glycemic Control

116. Hb A 1c: Delay DN DCCT Research Group. New Engl J Med 329:977, 1993

118. Decline of GFR in DN

119. Questions?

120. Chronic Kidney Disease: A Silent Epidemic (Part 2) Naima Ogletree, MSN, APRN, BC Nephrology & Hypertension Henry Ford Health System

121. Proteinuria Reduction

122. CKD: Albuminuria G Remuzzi, et al. New Engl J Med. 2002; 346:1145–1150.

124. RAAS, Albuminuria and Atherosclerosis Steno Hypothesis American Journal of Kidney Diseases, Vol 47, No 6 (June), 2006: pp 927-946

126. Albuminuria Decreases Survival Graded Effect Gall MA, et al. Diabetes 1995;44:1303-1309

127. UPC @ 6 Mo Predicts Kidney & CVD Events RENAAL Substudy (losartan, no ACEI) RENAAL Study Group, 2002 CV events 0.4 0.6 0.2 0.8 1 1.2 Hazard ratio (95 % C.I.) ← Less Risk More Risk -> ESRD CHF Proteinuria (g)

130. How RAAS Blockade is Beneficial Adapted from Hall JE et al. J Am Soc Nephrol . 1999;10:S258-S265. A Chagnac, et al. Glomerular hemodynamics in severe obesity. Am J Physiol 2000;278;F817-F822.

134. RENAAL: Combined CCB and ARB Reduce Progression to Diabetic Nephropathy Adapted from RENAAL Study. BM Brenner, et al. N Engl J Med. 2001;345:861–869. R AA , afferent arteriolar resistance. R EA , efferent arteriolar resistance. P eff P aff CCB P eff P aff NORMAL P GC  R AA ACEI (type 1 DM) ARB (type 2 DM)  R EA NORMAL P GC

135. IRMA 2: ARB Prevents Transition from Micro- to Macroalbuminuria H-H Parving, et al. New Engl J Med. 2001;345:870–878.

136. IRMA 2: ARB Prevents Transition from Micro- to Macroalbuminuria H-H Parving, et al. New Engl J Med. 2001;345:870–878. 0 3 6 12 18 22 24 0 5 10 15 20 Followup (mo) Control (n=201)* Irbesartan 150 mg/d (n=195)* Irbesartan 300 mg/d (n=194)* RRR=39% P =.08 RRR=70% P <.001 Incidence of Diabetic Nephropathy (%)

137. IRMA 2: ARB Normalizes Albumin Excretion Rate † P <0.05 H-H Parving, et al. New Engl J Med. 2001;870 –878. 35 45 40 30 25 20 15 10 5 0 Control † (n=201) 150 mg/d † (n=195) 300 mg/d † (n=194) Irbesartan 24 34 21 P =.006 Normal UAR (%)

138. Effect of AngII Receptor Blockade in Type 2 Diabetic Nephropathy BM Brenner, et al. N Engl J Med 2001;345:861 –869.

139. Irbesartan Diabetic Nephropathy Trial EJ Lewis, et al. N Engl J Med. 2001;345:851 –860.

140. R eduction in E ndpoints in N on-Insulin Dependent DM with the A ngiotensin II A ntagonist L osartan BM Brenner, et al. N Engl J Med 2001;345:861 –869.

142. Lipid Control

143. Guideline: Lipids in CKD 1–4 1.1. All adults and adolescents with CKD should be evaluated for dyslipidemias. (B) 1.2. For adults and adolescents with CKD, the assessment of dyslipidemias should include a complete fasting lipid profile with total cholesterol, LDL, HDL, and triglycerides. (B) 1.3. For adults and adolescents with Stage 5 CKD, dyslipidemias should be evaluated upon presentation (when the pt is stable), at 2–3 MO after a change in treatment or other conditions known to cause dyslipidemias; and at least annually thereafter. (B)

144. Dyslipidemia & CKD Treatment Protocol Lifestyle Modification … Always

145. Dyslipidemia & CKD Treatment Protocol Lifestyle Modification … Always

149. CKD: Lipid Targets Kidney/Dialysis Outcomes Initiative Clinical Practice Guidelines for Managing Dyslipidemias in Chronic Kidney Disease. Am J Kidney Dis 2003:41(Suppl 3):S1 – S91. NCEP ATP III <130 >40 <150 20.2% 15.1 K/DOQI Revision <100 >40 <150 38.9% — Parameter LDL-C (mg/dL) HDL-C (mg/dL) TG (mg/dL) Normal lipids (HD) Normal lipids (PD)

152. Anemia of CKD

154. CKD: Anemia Induces LVH Excerpt: H Hampl, L Henning and E Riedel. Dialysis Times 2003;9(5):1 – 6 A Mohanran and AS Kliger presentations at NKF Meeting 2003

158. CKD: Anemia  as GFR  Adapted from Radtke, et al. Blood. 1979;54:877 – 884 (original study used Hct). GFR (mL/min/1.73 m 2 ) Mean Hb* (g/dL)  91 90–40 39–30 29–20 19–10  10 n=18 n=59 n=18 n=34 n=18 n=29 5 6 7 8 9 10 11 12 13 14 15

159. RBC Production Response in CKD 0 1X 2X 3X 4X 5X 6X 0.1 1.0 10 10 2 10 3 10 4 EPO Concentration (mU/mL) RBC Production (mL/Day) Normal CKD

160. EPO Response Blunted as CKD Progresses Hemoglobin (g/dL) EPO level (mU/mL) Radtke HW. et al Blood 1979;54:877; Erslev AJ. N Engl J Med 1991;324:1339 100 - 70 70 - 40 40 - 25 25 - 15 15 - 10 <10 Percent of Normal Kidney Function 5 6 7 8 9 10 11 12 13 14 15 59 29 18 18 34 18 N = Expected EPO levels

161. Anemia: A Risk Multiplier Source : Medicare sample (5%), followup from 1996 to 1997 of enrollees aged > 65 y.o., adjusted for age, gender and race.

164. IV Iron May Have an Independent Erythropoietic Effect in HD *P <0.01 vs baseline. Fudin et al. Nephron. 1998;79:299 – 305. 39 new HD pts (no EPO therapy) with baseline iron deficiency by bone marrow aspiration. Hgb, g/dL * * 5 6 7 8 9 10 11 IV Iron Oral Iron No Iron Baseline 12 mo 26 mo

166. Available Oral Iron Preparations 2 150 150 Iron poly-saccharide 3 66 200 Ferrous fumarate 5 38 325 Ferrous gluconate 3 65 325 Ferrous sulfate No. Tablets to Supply 200 mg Elemental Fe Elemental Fe (mg/tablet) Strength (mg/tablet)

170. Chronic Kidney Disease—Mineral and Bone Disorder

172. Definition of Renal Osteodystrophy Renal osteodystrophy is an alteration of bone morphology in pts with CKD. It is one measure of the skeletal component of the systemic disorder of CKD-MBD that is quantifiable by histomorphometry of bone biopsy. Definition, evaluation, and classification of renal osteodystrophy. KI, April 2006 Position Statement from KDIGO ( K idney D isease I mproving G lobal O utcomes)

177. Progression of PTH Gland Hyperplasia in CKD VDR = vitamin D receptor; CaR = Ca-Sensing receptor. Adapted from Murayama A et al. Endocrinology . 1999;140:2224-2231. Satomura K et al. Kidney Int . 1988;34:712–716 CKD Progression Normal Diffuse Early nodular Nodular hyperplasia Single nodule Monoclonal nodules Decline in receptor density of VDR, CaR Cells with lower density of VDR proliferate vigorously to form several monoclonal nodules

178. CKD: Renal Osteodystrophy — Ca / P / PTH Axis KG Koenig, et al. Kidney Int. 1991;41:161–165. Alteration GFR Parameter Increased 40 - 70 PTH Increased 20 - 50 P i Decreased <40 Calcitriol Variable — Bone histology Alteration GFR Parameter  40 - 70 PTH  20 - 50 P  <40 Vitamin D 3 Variable — Bone histology

179. CKD: ROD PTH Target Low bone turnover Adynamic bone disease High bone turnover Bone pain Cardiovascular disease Cognitive impairment K/DOQI PTH Target (pg/mL) 100 150 300 500

180. CKD: ROD Ca Target K/DOQI Target Ca (mg/dL) 8.4 7.5 10.2 9.5 Stimulus for PTH secretion Stimulus for PT gland enlargement Inadequate skeletal mineralization Vascular/soft tissue calcification Hypertension

181. CKD: ROD P Target Malnutrition Inadequate bone mineralization Vascular/soft tissue calcification Cardiovascular disease Higher mortality risk K/DOQI Target P (mg/dL) 2.5 3.5 5.5 6.5

183. CKD: Renal Osteodystrophy —  P  Relative Risk of Mortality GA Block, et al. Am J Kidney Dis 1998;31:607–617.

184. Mortality Risk in ESRD by Serum P and Ca Levels RR = relative risk *Not adjusted for active vitamin D intake Block et al. J Am Soc Nephrol. 2004;15:2208-2218. Serum P (mg/dL) <3 3-4 4-5 7-8 8-9 >9 RR of Death* 0.0 0.8 1.0 1.2 1.4 1.6 1.8 2.0 2.2 5-6 6-7 N = 40,538 Serum Ca (mg/dL) 0.0 0.6 0.8 1.0 1.2 1.4 1.6 1.8 2.0 <8.0 8.0- 8.5 8.5- 9.0 9.0- 9.5 9.5- 10.0 10.0- 10.5 10.5- 11.0 >11.0

186. SHPT Occurs Early in CKD Martinez et al. NDT 1996;11:22-28. N=150 eGFR (mL/min/1.73 m 2 ) 15 25 35 45 55 65 75 85 95 105 100 200 300 400 0 10 20 30 40 iPTH (pg/mL) 1,25(OH) 2 D 3 Calcitriol (pg/mL) Stage 3 7.4 million Stage 2 5.7 million Stage 4 300,000 CKD Stage 1 5.6 million 25 70 target target

187. CKD-Mineral & Bone Disorder Ca/P/PTH Progression in CKD Martinez I, et al. Am J Kidney Dis. 1997;29:496-502. * P < 0.05,compared to CrCl > 100 and CrCl 50-59, N = 157 0 25 50 75 100 125 150 175 200 100+ 90-99 80-89 70-79 60-69 50-59 40-49 30-39 20-29 10-19 CrCl mL/m PTH, pg/mL 2 3 4 5 6 100+ 90-99 80-89 70-79 60-69 50-59 40-49 30-39 20-29 10-19 CrCl mL/m mg/dL Ionized Calcium PTH * * * Phosphorus

188. Recommendations for Early Monitoring of PTH, Ca, and P Metabolism in CKD GFR in mL/min/1.73 m 2 KDOQI Guidelines for Bone Metabolism and Disease. Am J Kidney Dis. 2003;42(4 suppl 3):S1-S201. 1 MO 3 MO <15 or ESRD 5 3 MO 3 MO 15 – 29 4 12 MO 12 MO 30 – 59 3 Measure Ca & P Measure PTH GFR Range CKD Stage

191. High-Turnover Bone Disease Can Result in Soft-Tissue Calcification PTH Calcium Magnesium Phosphorus Calcification Deposition Into Tissues

192. Low-Turnover Bone Disease Can Result in Soft-Tissue Calcification Calcium Magnesium Phosphorus Deposition Into Tissues Calcification PTH

196. A cidosis Aggravates Renal Osteodystrophy

198. Nutritional Assessment

207. Vaccinations

210. Influenza Vax rates Below National Target (Healthy People 2000) Gilbertson et al, Kidney Int 2003; 63:738-743; M MWR 2001, 50:532-37 _______________ __________________________ Dialysis pts General Population 60% 30% 60% 39% 49% 0% 10% 20% 30% 40% 50% 60% 70% 80% HD PD Whites Non Whites 2000

211. Odds of Hospitalization & Death are Reduced In Vaccinated HD pts _________________ __________________________ Hospitalization Death Gilbertson et al, Kidney Int 2003; 63:738-743

212. Evaluate Progression of CKD

217. AV Fistula

221. AV Grafts

223. Catheter Locations

224. Majority of Pts Start RRT Without A Permanent Vascular Access Held et al , AJKD 1996, 28 (Suppl. 2):58-78, USRDS DMMS I (1,997 pts incident in 1993) Permanent Access Placed or Attempted Before Start of RRT ?

225. Vascular Access Used for the First Chronic Hemodialysis Pisoni et al , Kidney Int 61:305-16, 2002. Random sample of 2,179 US and 875 European pts who began HD between 7/1996-10/2000 (US) and 7/1998-10/2000 (Europe) — DOPPS. 24% 60% 15% 66% 31% 2% 0% 10% 20% 30% 40% 50% 60% 70% AV Fistula AV Graft Catheter US Europe

226. Risk of Infectious Mortality is Increased with Temporary Access Dhingra et al , Kidney Int 60:1443-51, 2001. Adjusted for age, gender, race, BMI, smoking, education level, ability to ambulate, and history of PVD, CHD, CAD and cancer. P <0.02 P <0.06 Ref. Ref. P <0.33 P <0.04 AVF AVG CVC Diabetics Non-Diabetics AVF AVG CVC

227. Pts With Temporary Access Have Higher Rate of Hospital Utilization Arora et al , J Am Soc Nephrol , 11:740-7476 17.6 14.6 13.7 22.7 12.1 41.9 0 10 20 30 40 50 Overall First 3 months After 3 months Number of hospital days per patient-yr at risk Temporary Permanent

228. Vascular Access Survival and Revisions Gibson et al , J Vasc Surg 2001;34:694-700. Adjusted for age, gender, race, previous access NS <0.001 <0.05 <0.001 1.00 1.00 1.13 1.32 1.41 1.91 0.0 0.5 1.0 1.5 2.0 2.5 Primary Patency Revision aRR of Outcome AVFistula Transp Vein Fistula AVGraft

229. lla illi lla illi Prevalent hemodialysis pts from 2001 CPM data, year represents year in which dialysis was initiated; current access from 2001 CPM survey data; includes only pts for whom an access type is known. AVF (USRDS)

232. Questions?