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  • Rates of ESRD have been almost doubling each decade.
  • This slide compares ESRD to the 4 most serious cancers. While there is no intention to imply that one disease is worse than another, many people are not aware how the incidence of ESRD ranks. We know that people with ESRD can be sustained with transplants or dialysis. However, the mortality after ESRD is reached, particularly on dialysis, is so high (about 20% per year), that as many people die while being treated for uremia as from any cancer except lung cancer.
  • The pool of chronic kidney disease from which the cases of ESRD develop is very large. These data from the National Health and Nutrition Examination Survey (NHANES) indicate that about 19-20 million Americans have substantially depressed GFR and/or persistent microalbuminuria or even greater albuminuria.
  • Diabetes is the most rapidly rising cause of ESRD, but the hypertension rate also continues to rise.
  • This map shows the incidence rates for ESRD in 1990 with the highest rates in the Southeast.
  • This map from 10 years later shows that rates have increased dramatically throughout the US.
  • While rates of ESRD have risen in virtually all segments of the population certain groups have particularly high rates compared to the white population.
  • On the left of this slide are the total costs for caring for ESRD patients in 2002. About 2/3 of this cost comes from Medicare, the rest from various other largely private sources. As a comparison, the NIH budget during that same year is shown on the right and represents all of the NIH efforts for biomedical research in all fields - cancer, infection, heart disease, etc.
  • Premature cardiovascular death, not just ESRD, is a major risk for people with CKD. Recent studies have tightened the epidemiological link between CKD and CVD. These studies have reported a graded, inverse relation between initial renal function and subsequent risks of death and complications from cardiovascular disease. Some say, “Only the lucky CKD patients reach ESRD.”
  • Several therapies have been proven effective over the last 10 years. While not all people with CKD can have their disease process completely halted, significant slowing can be achieved and arrest of the process may be possible in some.
  • Despite the demonstration of effective therapy, screening of high-risk patients, referral and consultation with nephrologists, and even provision of therapy after diagnosis is inadequate.
  • Must an effective attack on this problem await major overhauls of our health care system? Many of these changes or even others may be desirable. Indeed, some such as disease management teams are even now developing. However, such wide-reaching alterations are unlikely in the near future.
  • Major system level changes may not be absolutely necessary for important change to occur. This graph shows the major declines in age-adjusted death rates for myocardial infarction and stroke over the last 30 or so years. The red vertical line marks the initiation of the High Blood Pressure Education Program in 1972. While many factors, better drugs, reduction in smoking campaigns by industry and many nonprofit groups, etc., have contributed to the remarkable improvements, educational efforts have almost surely had a major role.
  • Three major points that should be made: (1) 24- hour urine collections are not needed. They are not only cumbersome but may be even less accurate, at least for clearance/GFR than the equation. Spot urine for albuminuria is just as good as the collection. (2) A calculator with the MDRD equation is at the NKDEP website and a downloadable version is available. (3) The frequency of testing once a year is the consensus for diabetes and is the ADA guideline, but for the other risk groups (hypertension and family member with CKD) no evidence guidelines exist. Testing should be regular but some interval longer than that for diabetes - say 3 years - seems reasonable so long as the test remains normal.
  • NKDEP conducted a survey with 600 primary care providers. The hypothetical patient scenario at the top of the slide was posed. The majority of respondents gave an answer of 1.5 or greater. Using the MDRD equation, which the NKDEP recommends, or the older Cockcroft-Gault equation, this creatinine yields an estimated GFR of 37 or a creatinine clearance of 30, respectively. This demonstrate that in many cases physicians are waiting too long to diagnose CKD. For this patient scenario, ideally CKD would be diagnosed at a 1.0 creatinine or a GFR of 59 mL/min/1.73 m 2 .
  • Most of the ongoing care for people with early CKD can be provided by the PCP, but an early referral to a nephrologist for an opinion is useful. Once the estimated GFR is below 30 mL/min/1.73 m 2 , an allied care approach between the nephrology team and the PCP team is essential as complications tend to accelerate and careful planning for potential ESRD care is needed at this stage .
  • Diagnosing CKD at an early stage can add 2 or more years of ESRD-free survival. In some patients ESRD may actually be prevented. Careful attention to classic cardiovascular risk factors, especially smoking cessation and lipids, is also important to prevent premature cardiovascular death.
  • This simple calculation leads to the absurd conclusion that if all people with depressed GFR saw a nephrologist once a year, the nephrologists would be overwhelmed. If those with albuminuria were seen, the burden would be even twice as large. This leads to the inescapable conclusion that the PCPs must not only diagnose CKD but manage much of its care.
  • ckd

    1. 1. U.S. Department of Health and Human Services National Institutes of Health National Institute of Diabetes and Digestive and Kidney Diseases Chronic Kidney Disease in the United States
    2. 2. Reasons for a National Kidney Disease Education Program 1) Kidney failure is a public health problem 2) Economical, effective testing and therapy exist 3) Testing and therapy are inadequately applied
    3. 3. ESRD Rates Continue to Rise USRDS, 2004
    4. 4. Kidney Failure Compared to Cancer Deaths in the U.S. in 2000 (in Thousands) Seer, 2004 Lung Cancer Kidney Failure Colorectal Cancer Breast Cancer Prostate Cancer 57 100 41 30 160
    5. 5. Prevalence of Renal Insufficiency in U.S. Thus, about 8 million Americans have a GFR less than 60 mL/min/1.73 m2 . Plus 11 million more have a GFR over 60 but have persistent microalbuminuria. Coresh, et al., 2005 GFR (mL/min/1.73 m2 ) 59-30 29-15 Number of People 7.7 Million 360,000
    6. 6. Incident Counts & Adjusted Rates, By Primary Diagnosis USRDS, 2004
    7. 7. Incidence of Kidney Failure (per million population, 1990, by HSA, unadjusted) USRDS, 2000
    8. 8. Incidence of Kidney Failure (per million population, 2000, by HSA, unadjusted) USRDS, 2000
    9. 9. The Risk of Kidney Failure is Not Uniform Relative risks compared to Whites: African Americans 3.8 X Native Americans 2.0 X Asians/Pacific Islander 1.3 X The relative risk of Hispanics compared to non-Hispanics is about 1.5 X USRDS, 2004
    10. 10. Costs of Kidney Failure are High (in $billions for 2002) Kidney Failure Care Total NIH Budget 25.2 23.2Kidney Failure Accounts for 6% of Medicare Payments Lost Income for Patients is $2-4 Billion/Yr USRDS, 2004
    11. 11. CKD Predicts CVD 2.11 3.65 11.29 21.8 36.6 0 5 10 15 20 25 30 35 40 ≥ 60 45-59 30-44 15-29 < 15 Go, et al., 2004 Age-StandardizedRa Events(per100person-yr) Estimated GFR (mL/min/1.73 m2)
    12. 12. Treatment to Prevent Progression of CKD to Kidney Failure • Intensive glycemic control lessens progression from microalbuminuria in type 1 diabetes - DCCT, 1993 • Antihypertensive therapy with ACE Inhibitors lessens proteinuria and progression - Giatras, et al., 1997 - Psait, et al., 2000 - Jafar, et al., 2001 • Low protein diets lessen progression - Fouque, et al., 1992 - Pedrini, et al., 1996 - Kasiske, et al., 1998 Meta-Analyses Meta-Analyses
    13. 13. CKD is Not Being Recognized or Treated • Most practices screen fewer than 20% of their Medicare patients with diabetes* • Patients are referred late to a nephrologist, especially African-American men • Less than 1/3 of people with identified CKD get an ACE Inhibitor Kinchen, et al., 2002; McClellan et al.,1997 *Data provided by the USRDS based on 5 percent Medicare enrollment and claims data
    14. 14. Is “System Level” Action Necessary? • Universal medical coverage? • Disease management teams? • Improved reimbursement for prevention? • Other?
    15. 15. Age-Adjusted Cardiovascular Death is Declining
    16. 16. Parallels Between Hypertension in 1972 and Kidney Disease in 2005 • Recent documentation of effective therapy • Treatment of a silent disease to reduce risk for a disastrous outcome • Simple screening • Advantages for patients, physicians, industry
    17. 17. Who to Test for Chronic Kidney Disease Regular testing of people at risk • Diabetes • Hypertension • Relative with kidney failure • Cardiovascular disease
    18. 18. How to Test for Chronic Kidney Disease* In individuals with diabetes: • “Spot” urine albumin to creatinine ratio In others at risk: • “Spot” urine albumin to creatinine ratio OR standard dipstick (Bouleware, et al., 2003) • Estimate GFR from serum creatinine using the MDRD prediction equation *24 hour urine collections are NOT needed. Diabetics should be tested once a year. Others at risk testing less frequently as long as normal.
    19. 19. At What Level of Creatinine Does a 65-Year-Old Diabetic, Hypertensive White Woman Weighing 50 Kilograms Have CKD? • 77% said: Creatinine > 1.5 mg / dl • Creatinine = 1.0 for GFR = 59 mL/min/1.73 m2 GFR = 37 mL/min/ 1.73 m2 Ccreat = 30 mL/min
    20. 20. Who Should be Treated for Chronic Kidney Disease With diabetes: • With urine albumin/creatinine ratios more than 30mg albumin/1 gram creatinine Without diabetes: • With urine albumin/creatinine ratios more than 300mg albumin/1 gram creatinine corresponding to about 1+ on standard dipstick Or Any patient: • With estimated GFR less than 60 mL/min/1.73 m2
    21. 21. How to Treat for Chronic Kidney Disease • Maintain blood pressure less than 130/80 mmHg • Use an ACE Inhibitor or ARB • More than one drug is usually required and a diuretic should be part of the regimen • Continue best possible glycemic control in individuals with diabetes
    22. 22. How to Treat for Chronic Kidney Disease (continued) • Refer to dietician for a reduced protein diet • Consult a nephrologist early • Team with the nephrologist for care if GFR is less than 30 mL/min/1.73 m2 • Monitor hemoglobin and phosphorous with treatment as needed • Treat cardiovascular risk, especially smoking and hypercholesterolemia
    23. 23. Early Treatment Makes a Difference Brenner, et al., 2001
    24. 24. Target Audiences • African Americans with - Diabetes - Hypertension - Family history of kidney failure • Primary Care Providers
    25. 25. NKDEP Activities • “You Have The Power To Prevent Kidney Disease” awareness campaign • Improved laboratory measurements and routine reporting of kidney function • CKD quality indicators among Medicare beneficiaries hospitalized for cardiovascular disease • Consult letter template for nephrologists • Working with other non-profit, industry, and government groups
    26. 26. PCP Must be Engaged 1) 7.7 million people with GFR 30-60 mL/min/1.73 m2 2) About 5,000 full-time nephrologists 3) Nearly 1,500 new patients per nephrologist Therefore, 7 new patients per day per nephrologist. Obviously not possible.
    27. 27. What can Primary Care Providers do? • Recognize who is at risk • Provide testing and treatment • Encourage labs to provide and report estimated GFR and spot urine albumin/creatinine ratios
    28. 28. You Have The Power To Prevent Kidney Disease
    29. 29. References • Bouleware LE, Jaar BG, Tarver-Carr ME, Brancati FL, Powe NR. Screening for Proteinuria in US Adults: A cost-effectiveness analysis. Journal of the American Medical Association. 2003 Dec; 290(23):3101-3114. • Brenner BM, Cooper ME, de Zeeuw D, Keane WF, Mitch WE, Parving HH, Remuzzi G, Snapinn SM, Zhang Z, Shahinfar S, the RENAAL Study Investigators. Effects of Losartan on Renal and Cardiovascular Outcomes in Patients with Type 2 Diabetes and Nephropathy. New England Journal of Medicine. 2001 Sep 20;345(12):861-9. • Coresh J, Astor BC, Greene T, Eknoyan G, Levey AS. Prevalence of Renal Insufficiency in the U.S. American Journal of Kidney Disease. 2003 Jan;41(1):1-12. • Coresh J, Byrd-Holt D, Astor BC, Briggs JP, Eggers, PW, Lacher DA, Hostetter TH. Chronic Kidney Disease Awareness. Prevalence, and Trends among U.S. Adults, 1999 to 2000. Journal of the American Society of Nephrology. 2005 Jan;16(1):180-8. • Go AS, Chertow GM, Fan D, McCulloch CE, Chi-Yuan H. Chronic Kidney Disease and the Risks of Death, Cardiovascular Events, and Hospitalization. New England Journal of Medicine. 2004 Sep 23;351(13):1296-1305.
    30. 30. References (continued) • Kinchen KS, Sadler J, Fink N, Brookmeyer R, Klag MJ, Levey AS, Powe NR. The Timing of Specialist Evaluation in Chronic Kidney Disease and Mortality. Annals of Internal Medicine. 2002 Sep 17;137(6):479-86. • McClellan WM, Ramirez SP, Jurkovitz C. Screening for Chronic Kidney Disease: Unresolved Issues. Journal of the American Society of Nephrology. 2003 Jul;14 (7 Suppl 2):S81-7. Review. • McClellan WM, Knight DF, Karp H, Brown WW. Early Detection and Treatment of Renal Disease in Hospitalized Diabetic and Hypertensive Patients: Important Differences Between Practice and Published Guidelines. 1997 Mar;29(3):368- 75. • National Diabetes Information Clearing House. Diabetes Control and Complications Trial (DCCT). Bethesda (MD): National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, US Department of Health and Human Services; 1993 (NIH Publication No. 02-3874). Available from:
    31. 31. References (continued) • Ries LAG, Eisner MP, Kosary CL, Hankey BF, Miller BA, Clegg L, Mariotto A, Fay MP, Feuer EJ, Edwards BK (eds). SEER Cancer Statistics Review, 1975-2000, National Cancer Institute. Bethesda, MD,,2003. • U.S. Renal Data System, USRDS 2004 Annual Data Report: Atlas of End-Stage Renal Disease in the United States, National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD, 2004. • U.S. Renal Data System, USRDS 2003 Annual Data Report: Atlas of End-Stage Renal Disease in the United States, National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD, 2003. • U.S. Renal Data System, USRDS 2000 Annual Data Report: Atlas of End-Stage Renal Disease in the United States, National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD, 2000.