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Chronic Kidney Disease: Collaborative Care Through The Stages.   Family Medicine Grand Rounds University of Virginia Janua...
Disclosure Statements <ul><li>Current ACCME guidelines state that participants in CME activities should be made aware of a...
Outline/Objectives <ul><li>Define CKD </li></ul><ul><li>Review national and local epidemiology + outcome data </li></ul><u...
NKF K/DOQI Definition: Chronic Kidney Disease <ul><li>Structural or functional abnormalities of the kidneys for </li></ul>...
Staging Classification of CKD: NKF-K/DOQI  2002 Jan 23 2009  12:30 PM Collaborative Care of CKD <15 or dialysis Kidney fai...
Prevalence of Renal Insufficiency in US  “20 million CKD; 20 million at risk” Jan 23 2009  12:30 PM Collaborative Care of ...
Incidence & Prevalence trends in CKD/ESRD: “The Epidemic” <ul><li>Epidemic ESRD in the United States :  McClellan 1994 Art...
US Prevalence of CKD <ul><li>20 million Americans with CKD </li></ul><ul><li>20 million at risk of CKD </li></ul><ul><li>M...
CKD: Virginia and West Virginia <ul><li>4/2003, over 8,100 Virginians on kidney dialysis  </li></ul><ul><li>798,000 people...
Chronic Kidney Disease (CKD) <ul><li>Common condition (20m in US, 1 in 9) </li></ul><ul><li>Significant morbidity  </li></...
Disparities in ESRD Incidence   Incident ESRD patients; rates by age adjusted for gender & race, rates by race & ethnicity...
USRDS ADR, 2007 Prevalence of ESRD has been rising steadily
General Population Transplant Dialysis USRDS 2006 General Population Transplant Dialysis
Economics <ul><li>Public Law 92-603: 1973 Congress Medicare </li></ul><ul><li>$12.04 billion: cost of care for ESRD patien...
Costs of Kidney Failure are High (in $billions for 2002) Jan 23 2009  12:30 PM Collaborative Care of CKD USRDS, 2004 Kidne...
Kidney Failure (ESRD) in the US Lung Cancer Kidney Failure Colon Cancer Breast Cancer Prostate Cancer 57 99 42 32 Kidney F...
Causes of CKD   Jan 23 2009  12:30 PM Collaborative Care of CKD USRDS 1999. Annual Report.  Am J Kid Dis .:S40. 40% 27% 11...
Optimal Therapy In CKD <ul><li>Quality of life </li></ul><ul><li>Disease treatment </li></ul><ul><li>Progression preventio...
Later collaboration: associations <ul><li>Metabolic abnormalities </li></ul><ul><li>Prolonged hospitalization </li></ul><u...
Timing of Specialist Evaluation in CKD & Mortality <ul><li>National prospective cohort study </li></ul><ul><li>828 patient...
Benefits of Early Collaboration PCP: Nephrologist  Schoolwerth <ul><li>Informed selection of dialysis modality </li></ul><...
Late versus Early Collaboration older/retrospective <ul><li>Bonomini. Kidney Int (1985) 28:S57-S59. </li></ul><ul><li>Jung...
..follow-up and outcomes among a population with CKD… <ul><li>BACKGROUND: natural history of CKD with regard to progressio...
Improving Mortality   in ESRD:  <ul><li>Malnutrition </li></ul><ul><li>Dialysis Adequacy </li></ul><ul><li>Co-morbidities ...
CKD is Not Being Recognized or Treated <ul><li>Most practices screen fewer than 20% of their Medicare patients with diabet...
People At Increased Risk for CKD <ul><li>diabetes  </li></ul><ul><li>high blood pressure  </li></ul><ul><li>a family histo...
<ul><li>Diabetes mellitus </li></ul><ul><li>Hypertension </li></ul><ul><li>Cardiovascular disease </li></ul><ul><li>Family...
<ul><li>Family history of polycystic kidney disease or other genetic kidney disease </li></ul><ul><li>Renal dysplasia or h...
What to do?: 2 simple tests will identify CKD in adults <ul><li>eGFR -  Estimated GFR from serum creatinine using the MDRD...
Jan 23 2009  12:30 PM Collaborative Care of CKD Serum creatinine is frequently misleading 65yr old white woman with Cr 1.5...
<ul><li>MDRD estimating equation is not applicable to children </li></ul><ul><li>Updated Schwartz formula provides reasona...
Perils of using serum creatinine to “guess” level of renal function ≥ 60  mL/min/1.73 m 2 45  mL/min/1.73 m 2 59  mL/min/1...
Serum Creatinine: Pitfalls •  Circadian rhythm   •  Tubular secretion •  Menstrual cycle   •  Inhibition of tubular secret...
Primary MDs Must be Engaged <ul><li>7.7 million people with GFR 30-60 mL/min/1.73 m 2 </li></ul><ul><li>About 5,000 full-t...
Stages in Progression of CKD Therapeutic Strategies CKD death Complications Screening  for CKD risk factors: diabetes hype...
Kidney damage and Normal or    GFR Kidney damage and  Mild     GFR   Severe   GFR Kidney failure Moderate     GFR Stag...
Jan 23 2009  12:30 PM Collaborative Care of CKD Kidney Care Recommendations GFR*   ( Degree of interaction) Referral ml/mi...
Early treatment can make a difference 100 10 0 No Treatment Current Treatment Early Treatment 4 7 9 11 Time  (years) Kidne...
What can primary physicians do? <ul><li>Recognize and test at-risk patients  </li></ul><ul><li>Educate patients about CKD ...
What can primary physicians do?  (Continued) <ul><li>Monitor eGFR and UACR </li></ul><ul><li>Treat cardiovascular risk, es...
Nephrology referral suggestions <ul><li>To assist with diagnostic challenge (e.g. decision to biopsy) </li></ul><ul><li>To...
Nephrology referral suggestions, cont. <ul><li>Regardless of when you refer: </li></ul><ul><ul><li>Obtaining preliminary e...
Primary Physicians –  First line of defense against CKD <ul><li>Primary care professionals can play a significant role in ...
Team Approach: Role of PCP and Nephrologist in CKD Jan 23 2009  12:30 PM Collaborative Care of CKD <ul><li>Screen and iden...
Teamwork to Improve Patient Care <ul><li>Improve collaboration by the following: </li></ul><ul><ul><li>Enhancing prompt co...
Consequences of Lack  of Education During CKD <ul><li>Patients less likely to  </li></ul><ul><ul><li>Have functioning dial...
Benefits of Early Collaboration <ul><li>Informed selection of dialysis modality </li></ul><ul><li>Timely placement of vasc...
Chronic Kidney Disease: Collaborative Care Through The Stages.  (Part 2) Family Medicine Grand Rounds University of Virgin...
Disclosure Statements <ul><li>Current ACCME guidelines state that participants in CME activities should be made aware of a...
Outline/Objectives <ul><li>Define CKD </li></ul><ul><li>Review national and local epidemiology + outcome data </li></ul><u...
Teamwork in CKD Care Jan 23 2009  12:30 PM Collaborative Care of CKD Cardiologist PCP Dietician Nephrologist Patient Nurse...
Associated Systemic Complications in Chronic Kidney Disease (CKD) <ul><li>Anemia of CKD </li></ul><ul><li>Hypertension </l...
Work-up of Anemia of CKD: When? <ul><li>Normal  </li></ul><ul><ul><li>12 – 14 Hb g/dL (Hct 36-42) </li></ul></ul><ul><li>A...
Erythropoiesis in CKD Jan 23 2009  12:30 PM Collaborative Care of CKD <ul><ul><ul><li>Adapted from : Fauci. Harrison’s  Pr...
Anemia of CKD <ul><li>Primary cause: deficiency of erythropoietin </li></ul><ul><li>(absolute or relative) </li></ul><ul><...
Evaluation of anemia of CKD <ul><li>assessment of other reasons for anemia </li></ul><ul><li>Iron stores, folate, and vita...
Assessment of Anemia In Renal Disease <ul><li>If GFR  <  60 ml/min/1.73m 2  (Stage 3), consider anemia of renal origin </l...
Evaluation of anemia of CKD <ul><li>Hemoglobin and/or hematocrit </li></ul><ul><li>Red blood cell indices </li></ul><ul><l...
Clinical Consequences:  untreated Anemia of CKD <ul><li>Cardiovascular </li></ul><ul><ul><li>Left ventricular hypertrophy ...
Anemia and LVH Jan 23 2009  12:30 PM Collaborative Care of CKD Prevalence of LVH (% Patients) 0 10 20 30 40 50 >50 35 – 49...
LVH in CKD <ul><li>LVH is an independent predictor of cardiac death. </li></ul><ul><li>Hypertension, anemia, and diabetes ...
Impact: Anemia of CKD on Outcomes Jan 23 2009  12:30 PM Collaborative Care of CKD Chronic Kidney Disease in USACPMPM= cost...
Treatment: Anemia of CKD <ul><li>Recombinant erythropoietin </li></ul><ul><ul><li>Epoetin alfa </li></ul></ul><ul><ul><li>...
Epoetin and Management of Anemia <ul><li>NKF-K/DOQI Guidelines  </li></ul><ul><li>Target Hct 33%–36% (Hb 11–12 g/dL)* </li...
Erythropoietin Treatment <ul><li>Epoetin is administered weekly in an incremental dose that commonly starts from 50-100uni...
Epoetin Management: Monitoring <ul><li>Starting dose 50–100 U/kg IV or SC qW (‘tiw’) </li></ul><ul><li>Ensure good blood p...
Correction of anemia of CKD: many positive effects   <ul><li>Improved/increased </li></ul><ul><li>energy, physical strengt...
Jan 23 2009  12:30 PM Collaborative Care of CKD Epoetin  Improves Health-Related Quality-of-Life Scores For all scales, sc...
Jan 23 2009  12:30 PM Collaborative Care of CKD Adapted from NKF.  Am J Kidney Dis.  2001;37(suppl 1):S182. Anemia of CKD:...
Current Care of Anemia in Patients With CKD is Sub-optimal <ul><li>Mean Hct at start of dialysis: 29%*  </li></ul><ul><li>...
Data to Support Ideal Hemoglobin Target (1): Normal hematocrit (hemodialysis) CHOIR (pre-dialysis) 10 14 11.3 13.5 ↓  morb...
“ Epo Resistance”  Poor response to Epoetin Rx <ul><li>Fe deficiency </li></ul><ul><li>Fe deficiency </li></ul><ul><li>Fe ...
<ul><ul><li>Poor nutrition </li></ul></ul><ul><ul><li>Blood loss </li></ul></ul><ul><li>Increased iron needs </li></ul>Iro...
Assessment of Iron Status Jan 23 2009  12:30 PM Collaborative Care of CKD NKF.  Am J Kidney Dis.  2001;37(suppl 1):S182. M...
Administration of IV Iron: Dosage Jan 23 2009  12:30 PM Collaborative Care of CKD 100 mg 125 mg 1000 mg Maximum  Single Do...
Administration of IV Iron: Safety <ul><li>Adverse Events Reported </li></ul><ul><li>Hypotension </li></ul><ul><li>Nausea, ...
Possible Inadequacy of Oral Iron <ul><li>Low intestinal absorption of oral iron, even in healthy persons </li></ul><ul><li...
Iron Therapy: Summary <ul><li>Likely need for iron during Epoetin therapy </li></ul><ul><li>Oral iron </li></ul><ul><ul><l...
Management: “Epo Resistance” Inadequate Correction of Anemia Jan 23 2009  12:30 PM Collaborative Care of CKD NKF.  Am J Ki...
Associated Systemic Complications in Chronic Kidney Disease (CKD) <ul><li>Anemia of CKD </li></ul><ul><li>Hypertension </l...
Hypertension and CKD Jan 23 2009  12:30 PM Collaborative Care of CKD CKD Hypertension Zabetakis.  Am J Kidney Dis.  2000;3...
Blood Pressure Is Poorly Controlled in CKD Jan 23 2009  12:30 PM Collaborative Care of CKD Coresh.  Arch Intern Med . 2001...
Benefits of BP Control in CKD <ul><li>   Rate of progression of kidney disease, especially in patients with diabetes  </l...
HTN: Goal Blood Pressure Control Jan 23 2009  12:30 PM Collaborative Care of CKD JNC VII. JAMA 2003;289:2560. 140/90 mm Hg...
Blood Pressure Control in CKD: Goals Jan 23 2009  12:30 PM Collaborative Care of CKD JNC VI.  Arch Intern Med.  1997;157:2...
BP Control: Interventions <ul><li>ACE inhibitors </li></ul><ul><li>Angiotensin-receptor blockers (ARBs) </li></ul><ul><li>...
ACE Inhibitors Recommended for Slowing the Progression of CKD   <ul><li>Unless contraindicated, patients with hypertension...
Effect of Lisinopril on Progression of CKD Jan 23 2009  12:30 PM Collaborative Care of CKD Cinotti.  Nephrol Dial Transpla...
Effect of Lisinopril on Progression of CKD  (cont’d) Jan 23 2009  12:30 PM Collaborative Care of CKD Conventional 0 12 24 ...
Associated Systemic Complications in Chronic Kidney Disease (CKD) <ul><li>Anemia of CKD </li></ul><ul><li>Hypertension </l...
2 °  Hyperparathyroidism:  Natural History Jan 23 2009  12:30 PM Collaborative Care of CKD <ul><li>Multisystemic Toxicity ...
Jan 23 2009  12:30 PM Collaborative Care of CKD Renal Osteodystrophy: Full Spectrum Adynamic bone Osteomalacia Normal Mild...
Elevated PTH: Multisystemic Toxicity <ul><li>Widespread systemic effects </li></ul><ul><li>Insidious effects </li></ul><ul...
Toxicity of PTH <ul><li>High turnover lesions </li></ul><ul><li>Osteitis Fibrosa </li></ul><ul><li>Brown Tumors </li></ul>...
Long-Term Consequences of  Secondary Hyperparathyroidism <ul><li>Osteitis fibrosa </li></ul><ul><li>Vascular calcification...
PTH levels & Relative Risk of Death Jan 23 2009  12:30 PM Collaborative Care of CKD pg/mL Chertow  ASN 2000
Jan 23 2009  12:30 PM Collaborative Care of CKD <ul><ul><ul><ul><ul><li>Block GA,  Am J Kidney Dis. 1998;31:607-617. </li>...
Jan 23 2009  12:30 PM Collaborative Care of CKD Higher Ca    P Product: Higher Mortality Risk <ul><ul><ul><ul><ul><li>Blo...
Jan 23 2009  12:30 PM Collaborative Care of CKD Llach, et  al. AJKD, 32,4 Supp2, 1998:S3-12 GFR, ml/m Calcitriol, pg/ml 15...
Renal Osteodystrophy:  CKD 3&4 Jan 23 2009  12:30 PM Collaborative Care of CKD Phosphate retention Calcitriol Deficiency H...
Phosphorus Retention/Vitamin D Deficiency <ul><li>Phosphorus retention should be treated by dietary phosphorus restriction...
Metabolic Acidosis <ul><li>Occurs in all patients, usually when GFR  <  30 ml/min (Stage 4 CKD) </li></ul><ul><li>Conseque...
Renal Osteodystrophy: Management <ul><li>↓ P diet (.8-1g/d)+Fix acidosis:HCO 3 >22 mmol/L </li></ul><ul><li>Binders: P>5mg...
CKD stages 3&4:  Acid-Base <ul><li>Monitor serum bicarbonate acidosis: </li></ul><ul><li>HCO 3 >22 mmol/L </li></ul><ul><l...
Management: R enal Osteodystrophy <ul><li>Control serum phosphorus (3.0-5.0 mg/dL) </li></ul><ul><li>Prevent or reverse ac...
Target Values <ul><li>Phosphorus:  3.0 - 5.0 mg/dL – ideal </li></ul><ul><li>Calcium:  normal range ( 8.5-9.6 mg/dL) </li>...
Associated Systemic Complications in Chronic Kidney Disease (CKD) <ul><li>Anemia of CKD </li></ul><ul><li>Hypertension </l...
CKD stages 3&4: N utrition <ul><li>Dietary Restrictions/  Nutritional counseling </li></ul><ul><li>Lifestyle/dietary modif...
HYPERLIPIDEMIA <ul><li>CKD classified as high risk, ATPIII </li></ul><ul><li>Yearly or more frequent lipid profile per GFR...
Eating Well and Exercise <ul><li>Protein malnutrition is common in CKD. </li></ul><ul><li>Consider dietary protein restric...
Associated Systemic Complications in Chronic Kidney Disease (CKD) <ul><li>Anemia of CKD </li></ul><ul><li>Hypertension </l...
Diabetes: The Most Common Cause of ESRD Jan 23 2009  12:30 PM Collaborative Care of CKD Primary Diagnosis for Patients Who...
Pathogenesis of Diabetic Nephropathy <ul><li>Early stage </li></ul><ul><ul><li>Renal and glomerular hypertrophy </li></ul>...
Pathogenesis of Diabetic Nephropathy <ul><li>Advanced stage </li></ul><ul><ul><li>Nodular glomerulosclerosis </li></ul></u...
Albuminuria Jan 23 2009  12:30 PM Collaborative Care of CKD ADA.  Diabetes Care . 2001;24(suppl 1):S69.  300  200  300 ...
Recommended Screening Tests for Renal Complications <ul><li>Serum creatinine </li></ul><ul><li>Urinalysis </li></ul><ul><u...
Recommended Screening Tests for Renal Complications <ul><li>If protein is negative on urinalysis: </li></ul><ul><li>Random...
Hypertension and  Diabetic Nephropathy  <ul><li>Important to progression of diabetic nephropathy </li></ul><ul><li>In type...
Effect of Blood Pressure on Progression of Nephropathy*  Jan 23 2009  12:30 PM Collaborative Care of CKD 95 98 101 104 107...
Decreased Albuminuria and GFR Jan 23 2009  12:30 PM Collaborative Care of CKD Rossing.  Diabetologia.  1994;37:511. r =0.7...
BP Control and Proteinuria Jan 23 2009  12:30 PM Collaborative Care of CKD * P <0.05 vs patients with MAP   92 Lewis et a...
Jan 23 2009  12:30 PM Collaborative Care of CKD Adler.  Br Med J.  2000;321:412.  Stratton.  Br Med J.  2000;321:405. Inci...
Excess Mortality With Hypertension and Proteinuria Jan 23 2009  12:30 PM Collaborative Care of CKD Status of hypertension ...
ACE Inhibitors Recommended for Patients With Diabetic Nephropathy  <ul><li>In patients with diabetic nephropathy, ACE inhi...
HOPE Trial: Study Design <ul><li>Double-blind, placebo-controlled study </li></ul><ul><ul><li>Ramipril: 10 mg/day </li></u...
CV Outcomes and Renal Disease Jan 23 2009  12:30 PM Collaborative Care of CKD 14.4 9.3 5.8 10.3 2.5 18.5 14.8 9.4 12.5 4.5...
Effect of ACE Inhibitors on Renal Disease Progression <ul><li>Prospective, double-blind, randomized trial </li></ul><ul><u...
Effect of ACE Inhibitors on Renal Disease Progression Jan 23 2009  12:30 PM Collaborative Care of CKD 0 5 10 15 20 25 30 3...
Treatment of Diabetic Nephropathy <ul><li>Inclusion criteria </li></ul><ul><ul><li>30 to 75 years of age </li></ul></ul><u...
Treatment of Diabetic Nephropathy Jan 23 2009  12:30 PM Collaborative Care of CKD Chronic Kidney Disease in USAACEI = angi...
Angiotensin-II Receptor  Antagonists in Type 2 Diabetes <ul><li>Randomized, double-blind, placebo-controlled study </li></...
Angiotensin-II Receptor Antagonists in Type 2 Diabetes: RENAAL Jan 23 2009  12:30 PM Collaborative Care of CKD Brenner.  N...
Angiotensin-II Receptor  Antagonists in Type 2 Diabetes <ul><li>Prospective, randomized, double-blind study </li></ul><ul>...
Jan 23 2009  12:30 PM Collaborative Care of CKD Angiotensin-II Receptor Antagonists in Type 2 Diabetes: IDNT * P =0.006 † ...
Treatment of Diabetic Nephropathy <ul><li>Choice of antihypertensive agent </li></ul><ul><ul><li>ACEI and/or ARB </li></ul...
Nutritional Restrictions <ul><li>Sodium </li></ul><ul><ul><li>Hypertensive/nephropathy patients </li></ul></ul><ul><ul><ul...
Dyslipidemia in  Diabetic Nephropathy <ul><li>Increased CHD morbidity and mortality risk  </li></ul><ul><ul><li>   athero...
Anemia in  Diabetic Nephropathy <ul><li>Normochromic and normocytic </li></ul><ul><li>May occur early in patients with dia...
Future Directions <ul><li>Role of ACE inhibitor/ARB combination therapy or ARB monotherapy in diabetic nephropathy </li></...
CKD Predicts CVD Jan 23 2009  12:30 PM Collaborative Care of CKD Go, et al., 2004 Age-Standardized Rate of Cardiovascular ...
Cardiovascular Risk Intervention In CKD •  Weight loss to < 120% ideal BW  • Antiplatelet agents -bASA, ASA •  Treat malnu...
Risk Factors: Development & Progression of CKD <ul><ul><ul><li>Hypertension </li></ul></ul></ul><ul><ul><ul><li>Diabetes <...
Risk Factors for CKD <ul><li>Diabetes </li></ul><ul><li>Hypertension </li></ul><ul><li>Age </li></ul><ul><li>Family histor...
Risk Factors for CKD (Cont.) <ul><li>Coexisting kidney disease </li></ul><ul><li>Anemia </li></ul><ul><li>High-protein die...
Recommended Screening Tests for Patients at Risk for CKD <ul><li>SCr  </li></ul><ul><li>Blood pressure </li></ul><ul><li>G...
Improving Upon SCr Screening <ul><li>Example:  </li></ul><ul><ul><li>80-year-old woman, 50-kg body weight,  1.5 mg/dL SCr ...
Screening for CKD:  SCr vs Ccr <ul><li>Retrospective study of 2781 patients referred by community physicians </li></ul><ul...
Optimal CKD Patient Care Jan 23 2009  12:30 PM Collaborative Care of CKD Early Detection of CKD Delay progression ACE inhi...
Treatment of Metabolic Acidosis in CKD <ul><li>Goal  </li></ul><ul><ul><li>Serum HCO 3 - > 20 mEq/L </li></ul></ul><ul><ul...
Jan 23 2009  12:30 PM Collaborative Care of CKD Events in Chronic Kidney Disease © Copyright 2003 MedPoint Communications,...
Vascular Access  Ifudu NEJM 1998 (15) 339- Jan 23 2009  12:30 PM Collaborative Care of CKD Native Arteriovenous Fistula Ne...
Who Should be Treated for Chronic Kidney Disease? <ul><li>With diabetes : </li></ul><ul><li>With urine albumin/creatinine ...
How to Treat for Chronic  Kidney Disease <ul><li>Maintain blood pressure less than 130/80 mmHg </li></ul><ul><li>Use an AC...
Jan 23 2009  12:30 PM Collaborative Care of CKD Questions? NKF:  www.kidney.org NKF-Va:  www.kidneyva.org   NKDEP  www.nkd...
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  • Izinkan sy berkongsi kisah benar mengenai arabic gum kpd Tuan/Puan.

    kisahnya macam ni.
    setahun yang lalu pakcik sy mengalami sakit buah pinggang peringkat akhir dan menjalani rawatan dialisis di Hospital Pulau Pinang. makcik sy datang dari Sudan datang menziarahi pakcik dan membawa 'Arabic Gum' untuk pakcik.
    selepas kurang 10 hulan mengamalkan makanan dari syurga ini, Alhamdulillah pakcik sembuh dari penyakit buah pinggang dan dialisis dihentikan.
    Dengan nada gembira pakcik hubungi makcik pada jun 2013 untuk ucap terima kasih dan meminta benih pohon akasia yang mengeluarkan 'Arabic Gum' itu untuk ditanam di rumah tapi sayangnya pohon akasia hanya boleh tumbuh di tempat asalnya saja iaitu sudan.

    Setelah membuat kajian kasihatan dan pasaran, sy dan makcik bersetuju untuk membawa Arabic Gum ke Malaysia dalam kuantiti yang banyak untuk tujuan beramal dan berniaga kerana cara pemakanannya amat mudah, amat murah dan paling penting ia berkesan (Dengan izin Allah).

    Tuan/Puan boleh dapatkan maklumat lanjut dgn menaipkan Arabic Gum / Getah Arab / Al Manna / Acacia Powder di Internet.
    Di negara arab ia digelar 'Bread from heaven' kerana Arabic Gum atau Al manna ini ada disebut di dalam kitab Al-Quran dalam surah Al-baqarah ayat 57.
    Info:-
    Getah Arab ini hanya terdapat di Sudan. Tidak hairanlah kenapa negara Sudan menjadi rebutan sesetengah pihak.

    Getah Arab (Gum Arabic) sejenis prebiotik asli yang hanya terdapat di Sudan mempunyai potensi dalam industri perubatan, makanan dan solek antarabangsa akan dapat menguatkan kedudukan Malaysia sebagai sebuah hab halal dengan adanya penyelidikan rapi mengenainya yang dipelopori UKM.

    Ramli, 41 tahun, adalah juga bukti khasiat getah ini kerana beliau dahulu terpaksa menjalani rawatan dilasis tiga kali seminggu kerana buah pinggangnya sudah tidak berfungsi. Berkat penggunaan getah itu selama tujuh bulan buah pinggangnya sudah puleh dan beliau sejak 10 bulan kebelakangan ini tidak lagi perlu menjalani rawatan itu.

    Prebiotik adalah sejenis makanan untuk bakteria semula jadi yang terdapat dalam perut yang menentukan pengkhadaman makanan dapat berfungsi dengan baik. Bahan ini kini terdapat dalam makanan seperti berteh, beberapa jenis roti dan juga kapsul kebanyakannya di impot dari Barat.

    Kelebihan getah Arab dari Sudan ini ialah lebih 90 peratus daripadanya adalah jenis terbaik dan diperolehi secara semula jadi dari dua jenis pohon acasia yang hanya boleh di tanam di Sudan. Usaha menanamnya di negara jiran Sudan seperti Chad dan juga di Amerika telah gagal.

    Penyelidikan Terhadap Khasiat Getah Arab di UKM
    Rabu, 29 Jun 2011
    http://www.ukm.my/news/index.php/ms/berita-kampus/758-ukms-research-into-gum-arabic-set-to-create-international-demand-for-it-.html




    Sungguh niat sy hanya ingin membantu sesama saudara islam sy atau sesisapa sahaja.
    kami menjualnya dengan harga yang amat murah RM45(untuk pos) RM40 (C.O.D = cash on delivery), boleh tahan untuk sebulan.(boleh bandingkan dgn kos rawatan dialisis sebulan).

    ruangan ini amat terbatas untuk beri penerangan dengan jelas tentang apa itu arabic gum, so jangan segan untuk hubungi sy atau sms sy pun boleh untuk dapatkan informasi lebih lanjut. insya Allah sy akan beri gambaran jelas tentang Arabic Gum ini.

    Tuan/Puan boleh hubungi sy di:
    samsurijal 0128634538
    andreaboy786@gmail.com

    sekian wassalam
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file kidney disease

  1. 1. Chronic Kidney Disease: Collaborative Care Through The Stages. Family Medicine Grand Rounds University of Virginia January 23, 2009 Rasheed A Balogun, MD FACP FASN Division of Nephrology, University of Virginia Charlottesville, VA
  2. 2. Disclosure Statements <ul><li>Current ACCME guidelines state that participants in CME activities should be made aware of any affiliation or financial interest that may affect the faculty member’s contributions. Each faculty member has completed a statement of disclosure, which includes funding sources other than the honorarium received for this program. The faculty have provided the following information on sources of funding that may be perceived as a potential conflict of interest. </li></ul><ul><li>Rasheed Balogun </li></ul><ul><li>: research funding from National Kidney Foundation-Vas </li></ul><ul><li>: received honoraria from Abbott Laboratories and Genzyme Therapeutics </li></ul><ul><li>: board member (chair MAB), NKF-Va </li></ul><ul><li>: will not discuss any non-FDA approved products </li></ul>Jan 23 2009 12:30 PM Collaborative Care of CKD
  3. 3. Outline/Objectives <ul><li>Define CKD </li></ul><ul><li>Review national and local epidemiology + outcome data </li></ul><ul><li>Review CKD: Clinical Action Plan </li></ul><ul><ul><li>Detect CKD </li></ul></ul><ul><ul><li>Prevent progression of CKD </li></ul></ul><ul><ul><li>Diagnosis and treat CVD </li></ul></ul><ul><ul><li>Treat co-morbid conditions and complications </li></ul></ul><ul><ul><li>Refer to nephrology : Emphasize role of the non-nephrologist MD in CKD care </li></ul></ul>Jan 23 2009 12:30 PM Collaborative Care of CKD
  4. 4. NKF K/DOQI Definition: Chronic Kidney Disease <ul><li>Structural or functional abnormalities of the kidneys for </li></ul><ul><li>> 3 months, as manifested by either: </li></ul><ul><li>1. GFR <60 ml/min/1.73 m 2 , with/without kidney damage </li></ul><ul><li>2. Kidney damage, with/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>
  5. 5. Staging Classification of CKD: NKF-K/DOQI 2002 Jan 23 2009 12:30 PM Collaborative Care of CKD <15 or dialysis Kidney failure 5 15–29 Severe  GFR 4 30–59 Moderate  GFR 3 60–89* Mild  GFR 2 > 90 Chronic kidney damage with normal or  GFR 1 GFR Description Stage GFR: mL/min/1.73 m 2 *May be normal for age
  6. 6. Prevalence of Renal Insufficiency in US “20 million CKD; 20 million at risk” Jan 23 2009 12:30 PM Collaborative Care of CKD Thus, about 8 million Americans have a GFR less than 60 mL/min/1.73 m 2 . Plus 11 million more have a GFR over 60 but have persistent microalbuminuria Coresh, et al., 2005 GFR (mL/min/1.73 m 2 ) 59-30 29-15 Number of People 7.7 Million 360,000
  7. 7. Incidence & Prevalence trends in CKD/ESRD: “The Epidemic” <ul><li>Epidemic ESRD in the United States : McClellan 1994 Artif Organs </li></ul><ul><li>Trends in end-stage renal disease: Reikes 2000 Postgrad med </li></ul><ul><li>The national epidemic of chronic kidney disease : Eknoyan 2001 Postgrad med </li></ul>Jan 23 2009 12:30 PM Collaborative Care of CKD
  8. 8. US Prevalence of CKD <ul><li>20 million Americans with CKD </li></ul><ul><li>20 million at risk of CKD </li></ul><ul><li>Most do not know it and opportunities are missed </li></ul><ul><li>To prevent or treat kidney disease successfully: </li></ul><ul><li>The individual should be proactive </li></ul><ul><li>Have good health providers (Doctor, nurse, social worker, dietician etc) </li></ul>Jan 23 2009 12:30 PM Collaborative Care of CKD www.kidneyva.org
  9. 9. CKD: Virginia and West Virginia <ul><li>4/2003, over 8,100 Virginians on kidney dialysis </li></ul><ul><li>798,000 people in Virginia & 198,000 people in West Virginia have CKD </li></ul><ul><li>many do not know they have a problem </li></ul><ul><li>1,632 Virginians are on a waiting list for a kidney transplant. </li></ul><ul><li>Medicare-certified dialysis centers 1/2005:    Virginia - 122    West Virginia - 23 </li></ul>Jan 23 2009 12:30 PM Collaborative Care of CKD www.kidneyva.org
  10. 10. Chronic Kidney Disease (CKD) <ul><li>Common condition (20m in US, 1 in 9) </li></ul><ul><li>Significant morbidity </li></ul><ul><li>Expensive </li></ul>Jan 23 2009 12:30 PM Collaborative Care of CKD McCarthy JT. Mayo Clin Proc. 1999;74:269-273. Obrador GT et al. J Am Soc Nephrol. 1999;10:1793-1800. Consensus Development Conference Panel. Ann Intern Med . 1994;121:62-70. Effective treatment is available to slow rate of progression of CKD
  11. 11. Disparities in ESRD Incidence Incident ESRD patients; rates by age adjusted for gender & race, rates by race & ethnicity adjusted for age & gender. For Hispanic patients we present data beginning in 1996, the first full year after the April 1995 introduction of the revised Medical Evidence form, which contains more specific questions on race & ethnicity. USRDS 2006
  12. 12. USRDS ADR, 2007 Prevalence of ESRD has been rising steadily
  13. 13. General Population Transplant Dialysis USRDS 2006 General Population Transplant Dialysis
  14. 14. Economics <ul><li>Public Law 92-603: 1973 Congress Medicare </li></ul><ul><li>$12.04 billion: cost of care for ESRD patients in 1998 </li></ul><ul><li>Was 5% of total Medicare budget </li></ul><ul><li>Only 0.7% Medicare population had ESRD </li></ul><ul><li>Projected cost/yr by 2010: $28 billion </li></ul><ul><li>USRDS ADR 2000 </li></ul>Jan 23 2009 12:30 PM Collaborative Care of CKD
  15. 15. Costs of Kidney Failure are High (in $billions for 2002) Jan 23 2009 12:30 PM Collaborative Care of CKD USRDS, 2004 Kidney Failure Care Total NIH Budget 25.2 23.2 Kidney Failure Accounts for 6% of Medicare Payments (0.7% of population) Lost Income for Patients is $2-4 Billion/Yr
  16. 16. Kidney Failure (ESRD) in the US Lung Cancer Kidney Failure Colon Cancer Breast Cancer Prostate Cancer 57 99 42 32 Kidney Failure Compared to Cancer Deaths in the U.S. in 2000* (in Thousands) 157 *SEER, 2003 Male Female Black White 0.01 100 10 1 0.1 Annual mortality 25–34 45–54 65–74  85 35–44 55–64 75–84 Dialysis Age (years) General population
  17. 17. Causes of CKD Jan 23 2009 12:30 PM Collaborative Care of CKD USRDS 1999. Annual Report. Am J Kid Dis .:S40. 40% 27% 11% 4% 18% Diabetes Hypertension Glomerulonephritis Interstitial nephritis Other
  18. 18. Optimal Therapy In CKD <ul><li>Quality of life </li></ul><ul><li>Disease treatment </li></ul><ul><li>Progression prevention </li></ul><ul><li>Decrease comorbid conditions </li></ul><ul><li>Prevent CKD complications </li></ul><ul><li>Preparation for RRT </li></ul><ul><li>“ Don’t let the treatment be worse than the disease” </li></ul>Jan 23 2009 12:30 PM Collaborative Care of CKD
  19. 19. Later collaboration: associations <ul><li>Metabolic abnormalities </li></ul><ul><li>Prolonged hospitalization </li></ul><ul><li>Higher costs </li></ul><ul><li>Less informed selection of ESRD modalities </li></ul><ul><li>Delayed placement of permanent vascular access </li></ul><ul><li>Higher mortality in first year </li></ul>Jan 23 2009 12:30 PM Collaborative Care of CKD Obrador & Pereira. Am J Kidney Dis (1999) 31:398-417
  20. 20. Timing of Specialist Evaluation in CKD & Mortality <ul><li>National prospective cohort study </li></ul><ul><li>828 patients in 81 units nationwide </li></ul><ul><li>Nephrology: Early >12mo: Inter 4-12mo: Late <4mo </li></ul><ul><li>Average 2.2yrs f/u of death rate </li></ul><ul><li>“ Late evaluation of patients with CRF by a nephrologist is associated with greater burden and severity of comorbid disease, black ethnicity, lack of health insurance, and shorter duration of survival” </li></ul>Jan 23 2009 12:30 PM Collaborative Care of CKD Kinchen et al Ann Intern Med 2002 Sep 17;137(6):479-86
  21. 21. Benefits of Early Collaboration PCP: Nephrologist Schoolwerth <ul><li>Informed selection of dialysis modality </li></ul><ul><li>Timely placement of appropriate dialysis access </li></ul><ul><li>Timely initiation of dialysis </li></ul><ul><li>Lower morbidity </li></ul><ul><li>Less frequent and shorter hospital stays </li></ul><ul><li>Better rehabilitation </li></ul><ul><li>Lower costs </li></ul><ul><li>Lower mortality </li></ul>Jan 23 2009 12:30 PM Collaborative Care of CKD
  22. 22. Late versus Early Collaboration older/retrospective <ul><li>Bonomini. Kidney Int (1985) 28:S57-S59. </li></ul><ul><li>Jungers. Nephrol Dial Transplant (1993) 8:1089-1093 </li></ul><ul><li>Sesso & Belasco.Nephrol Dial Transplant (1996) 11:2417-2420 </li></ul><ul><li>Levin. Am J Kidney Dis (1997) 29:533-540 </li></ul><ul><li>Ellis. Q J Med (1998) 91:727-732 </li></ul><ul><li>Obrador & Pereira. Am J Kidney Dis (1998) 31:398-417 </li></ul><ul><li>Lameire & Van Biesen. Nephrol Dial Transplant (1999) 14 [Suppl 6]:16-21 </li></ul><ul><li>Ifudu. Am J Kidney Dis (1999) 33:728-733 </li></ul>Jan 23 2009 12:30 PM Collaborative Care of CKD
  23. 23. ..follow-up and outcomes among a population with CKD… <ul><li>BACKGROUND: natural history of CKD with regard to progression to RRT and death </li></ul><ul><li>METHODS: 27 998 patients with GFR <90 </li></ul><ul><li>followed up until RRT, death, disenrollment from the health plan, or 6/30/01 comorbidities: hypertension, diabetes mellitus, coronary artery disease, congestive heart failure, hyperlipidemia, and renal anemia. </li></ul><ul><li>RESULTS: Our data showed that the rate of RRT the 5-year observation period was 1.1%, 1.3%, and 19.9%, respectively, for the CKD stages 2, 3, and 4, but that the mortality rate was 19.5%, 24.3%, and 45.7%. </li></ul><ul><li>death was far more common than dialysis at all stages In addition, congestive heart failure, coronary artery disease, diabetes, and anemia were more prevalent in the patients who died but hypertension prevalence was similar across all stages. </li></ul><ul><li>CONCLUSION: Our data suggest that efforts to reduce mortality in this population should be focused on treatment and prevention of coronary artery disease, congestive heart failure, diabetes mellitus, and anemia. </li></ul>Jan 23 2009 12:30 PM Collaborative Care of CKD Keith DS et al Arch Int Med 2004;164:659-63
  24. 24. Improving Mortality in ESRD: <ul><li>Malnutrition </li></ul><ul><li>Dialysis Adequacy </li></ul><ul><li>Co-morbidities </li></ul><ul><li>Dialyzer type/reprocessing </li></ul><ul><li>CKD (Pre-ESRD) care </li></ul><ul><li>Other: Hyperphosphatemia, Depression </li></ul><ul><ul><li>?Timing of Initiation of RRT Obrador AJKD 1997 </li></ul></ul><ul><ul><li>?Timing of Specialist Evaluation in CKD Kinchen, Annals Sept 2002 </li></ul></ul>Jan 23 2009 12:30 PM Collaborative Care of CKD
  25. 25. CKD is Not Being Recognized or Treated <ul><li>Most practices screen fewer than 20% of their Medicare patients with diabetes* </li></ul><ul><li>Patients are referred late to a nephrologist, especially African-American men </li></ul><ul><li>Less than 1/3 of people with identified CKD get an ACE Inhibitor </li></ul>Jan 23 2009 12:30 PM Collaborative Care of CKD Kinchen, et al., 2002; McClellan et al.,1997 *Data provided by the USRDS based on 5 percent Medicare enrollment and claims data
  26. 26. People At Increased Risk for CKD <ul><li>diabetes </li></ul><ul><li>high blood pressure </li></ul><ul><li>a family history of CKD </li></ul><ul><li>older age </li></ul><ul><li>Race/Ethnicity: Relative risks compared to Whites: </li></ul><ul><li>African Americans 3.9 X </li></ul><ul><li>Native Americans 2.9 X </li></ul><ul><li>Asians 1.6 X </li></ul>Jan 23 2009 12:30 PM Collaborative Care of CKD
  27. 27. <ul><li>Diabetes mellitus </li></ul><ul><li>Hypertension </li></ul><ul><li>Cardiovascular disease </li></ul><ul><li>Family members of patients with ESRD </li></ul><ul><li>Note on pediatric patients: </li></ul><ul><ul><li>CKD may start with childhood obesity </li></ul></ul><ul><ul><li>No recommendations for routine testing </li></ul></ul>People to test:those at greatest risk
  28. 28. <ul><li>Family history of polycystic kidney disease or other genetic kidney disease </li></ul><ul><li>Renal dysplasia or hypoplasia </li></ul><ul><li>Urologic disorders—especially obstructive uropathies </li></ul>Hogg, et al., 2003 CKD is less common in children but there are risk factors
  29. 29. What to do?: 2 simple tests will identify CKD in adults <ul><li>eGFR - Estimated GFR from serum creatinine using the MDRD equation </li></ul><ul><li>UACR - Urine albumin to creatinine ratio on a “spot” urine sample </li></ul><ul><ul><ul><li>24-hour urine collections are NOT needed </li></ul></ul></ul><ul><li>- Diabetics should be tested once a year. Others at risk can be tested less frequently as long as normal. </li></ul>
  30. 30. Jan 23 2009 12:30 PM Collaborative Care of CKD Serum creatinine is frequently misleading 65yr old white woman with Cr 1.5mg/dl & 50Kg body weight Cockroft-Gault formula = (140-age[yr])(body wgt[kg]) x 0.85) 72 x serum creat (mg/dl) = 30ml/min MDRD GFR = 170 x [Pcr] -0.999 x [Age] -0.176 x [0.762 if patient is female ] x [1.180 if is patient is black ] x [SUN] -0.170 x [Alb] +0.318 = 37ml/min/1.73 m2 Cockcroft DW, Gault MH. Nephron . 16:31-41 1976 Levey et al. Ann Intern Med 130:461-470, 1999 Function: GFR! not Serum Creatinine
  31. 31. <ul><li>MDRD estimating equation is not applicable to children </li></ul><ul><li>Updated Schwartz formula provides reasonable estimate in children with mild-moderate CKD </li></ul><ul><li>(GFR – 15-75 mL/min/1.73 m 2 ) </li></ul>Estimation of GFR in children Updated Schwartz Formula eGFR = k * Ht/S cr Where k=0.4, Ht in cm and S cr in mg/dL and measured by enzymatic methodology
  32. 32. Perils of using serum creatinine to “guess” level of renal function ≥ 60 mL/min/1.73 m 2 45 mL/min/1.73 m 2 59 mL/min/1.73 m 2 24-yo Black Man 63-yo White Man 59-yo White Woman SCr 1.3 mg/dL 1.3 mg/dL 1.3 mg/dL GFR as estimated by MDRD Study equation
  33. 33. Serum Creatinine: Pitfalls • Circadian rhythm • Tubular secretion • Menstrual cycle • Inhibition of tubular secretion • Types of food • Determination variability • Method of food preparation • Collection variability • Muscle mass • Gender differences • Physical activity • Race differences • Cross reactive substances • Catabolic/anabolic state
  34. 34. Primary MDs Must be Engaged <ul><li>7.7 million people with GFR 30-60 mL/min/1.73 m 2 </li></ul><ul><li>About 5,000 full-time nephrologists </li></ul><ul><li>Nearly 1,500 new patients per nephrologist </li></ul><ul><li>Therefore, 7 new patients per day per nephrologist. Obviously not possible. </li></ul>Jan 23 2009 12:30 PM Collaborative Care of CKD
  35. 35. Stages in Progression of CKD Therapeutic Strategies CKD death Complications Screening for CKD risk factors: diabetes hypertension age >60 family history US ethnic minorities CKD risk reduction; Screening for CKD Diagnosis & treatment; Treat comorbid conditions; Slow progression Estimate progression; Treat complications; Prepare for replacement Replacement by dialysis & transplant Normal Increased risk Kidney failure Damage  GFR
  36. 36. Kidney damage and Normal or  GFR Kidney damage and Mild  GFR Severe  GFR Kidney failure Moderate  GFR Stage 1 Stage 2 Stage 3 Stage 4 Stage 5 All other health care providers GFR 90 60 30 15 Suggested Practice Model for Detection, Evaluation & Management in CKD At increased risk Kidney Specialist Primary physician
  37. 37. Jan 23 2009 12:30 PM Collaborative Care of CKD Kidney Care Recommendations GFR* ( Degree of interaction) Referral ml/min/1.73m 2 PCP Nephrologist interval Normal- 80- 60- 40- 30- 20- 10- 0- Education Access Placement RRT Progression Prevention Specific Indication at risk screening and intervention Consultation Renal Replacement Therapy (RRT) As needed Q 1-2 Years Q 6 Months Q 1-3 Months As Required *GFR – Glomerular Filtration Rate Primary Care Bolton & Owen, Postgrad Med 2002 Jun;111(6):97-8, 101-4, 107-8
  38. 38. Early treatment can make a difference 100 10 0 No Treatment Current Treatment Early Treatment 4 7 9 11 Time (years) Kidney Failure GFR (mL/min/1.73 2 )
  39. 39. What can primary physicians do? <ul><li>Recognize and test at-risk patients </li></ul><ul><li>Educate patients about CKD and treatment </li></ul><ul><li>Focus on good glycemic control in people with diabetes </li></ul><ul><li>For those with CKD: </li></ul><ul><ul><li>Blood pressure below 130/80 </li></ul></ul><ul><ul><li>Use an ACE inhibitor or ARB </li></ul></ul><ul><ul><li>More than one drug is usually required </li></ul></ul><ul><ul><li>A diuretic should be part of the regimen </li></ul></ul>
  40. 40. What can primary physicians do? (Continued) <ul><li>Monitor eGFR and UACR </li></ul><ul><li>Treat cardiovascular risk, especially with smokers and hypercholesterolemia </li></ul><ul><li>Screen for anemia (Hgb), malnutrition (albumin), metabolic bone disease (Ca, Phos, PTH) </li></ul><ul><li>Refer to dietitian for nutritional guidance </li></ul><ul><li>Consult or team with a nephrologist </li></ul><ul><li>Encourage labs to report estimated eGFR and urine albumin/creatinine ratios </li></ul>
  41. 41. Nephrology referral suggestions <ul><li>To assist with diagnostic challenge (e.g. decision to biopsy) </li></ul><ul><li>To assist with therapeutic challenge (e.g. blood pressure) </li></ul><ul><li>Rapid decay of estimated GFR </li></ul><ul><li>Most primary kidney diseases, (e.g. glomerulonephridites) </li></ul><ul><li>Preparation for renal replacement therapy, especially when GFR less than 30 </li></ul>
  42. 42. Nephrology referral suggestions, cont. <ul><li>Regardless of when you refer: </li></ul><ul><ul><li>Obtaining preliminary evaluation (e.g. ultrasound, screening serologies) </li></ul></ul><ul><ul><li>Providing consultant with patient history including serial measures of renal function </li></ul></ul>
  43. 43. Primary Physicians – First line of defense against CKD <ul><li>Primary care professionals can play a significant role in early diagnosis, treatment, and patient education </li></ul><ul><li>Therapeutic interventions for diabetic CKD are similar to those required for optimal diabetes care </li></ul><ul><ul><ul><li>Control of glucose, blood pressure, and lipids </li></ul></ul></ul><ul><li>A greater emphasis on detecting CKD, and managing it prior to referral, can improve patient outcomes </li></ul>CKD is Part of Primary Care
  44. 44. Team Approach: Role of PCP and Nephrologist in CKD Jan 23 2009 12:30 PM Collaborative Care of CKD <ul><li>Screen and identify risk factors of CKD, including: </li></ul><ul><ul><li>Diabetes </li></ul></ul><ul><ul><li>CVD </li></ul></ul><ul><ul><li>Anemia </li></ul></ul><ul><li>Provide ongoing management of patients with CKD </li></ul><ul><li>Provide role-specific patient education </li></ul>PCP <ul><li>Assist in development of care strategy </li></ul><ul><li>Aid recommendation and implementation of patient care </li></ul><ul><li>Provide role-specific patient education </li></ul>Nephrologist
  45. 45. Teamwork to Improve Patient Care <ul><li>Improve collaboration by the following: </li></ul><ul><ul><li>Enhancing prompt communication between the nephrologist and PCP </li></ul></ul><ul><ul><li>Recognize that each physician has a different approach and perspective on CKD patient care </li></ul></ul>Jan 23 2009 12:30 PM Collaborative Care of CKD
  46. 46. Consequences of Lack of Education During CKD <ul><li>Patients less likely to </li></ul><ul><ul><li>Have functioning dialysis access at initiation of RRT </li></ul></ul><ul><ul><li>Use home dialysis modality </li></ul></ul><ul><ul><li>Continue employment </li></ul></ul><ul><ul><li>Recognize treatable complications (eg, anemia) </li></ul></ul><ul><li>Patients more likely to </li></ul><ul><ul><li>Change modality after initiation of RRT </li></ul></ul>Jan 23 2009 12:30 PM Collaborative Care of CKD
  47. 47. Benefits of Early Collaboration <ul><li>Informed selection of dialysis modality </li></ul><ul><li>Timely placement of vascular access </li></ul><ul><li>Timely initiation of dialysis </li></ul><ul><li>Less frequent and shorter hospitalizations </li></ul><ul><li>Potentially less mortality </li></ul><ul><li>Lower incidence of anemia and malnutrition </li></ul>Jan 23 2009 12:30 PM Collaborative Care of CKD
  48. 48. Chronic Kidney Disease: Collaborative Care Through The Stages. (Part 2) Family Medicine Grand Rounds University of Virginia March 13, 2009 Rasheed A Balogun, MD FACP FASN Division of Nephrology, University of Virginia Charlottesville, VA
  49. 49. Disclosure Statements <ul><li>Current ACCME guidelines state that participants in CME activities should be made aware of any affiliation or financial interest that may affect the faculty member’s contributions. Each faculty member has completed a statement of disclosure, which includes funding sources other than the honorarium received for this program. The faculty have provided the following information on sources of funding that may be perceived as a potential conflict of interest. </li></ul><ul><li>Rasheed Balogun </li></ul><ul><li>: research funding from National Kidney Foundation-Vas </li></ul><ul><li>: received honoraria from Abbott Laboratories and Genzyme Therapeutics </li></ul><ul><li>: board member (chair MAB), NKF-Va </li></ul><ul><li>: will not discuss any non-FDA approved products </li></ul>Jan 23 2009 12:30 PM Collaborative Care of CKD
  50. 50. Outline/Objectives <ul><li>Define CKD </li></ul><ul><li>Review national and local epidemiology + outcome data </li></ul><ul><li>Review CKD: Clinical Action Plan </li></ul><ul><ul><li>Detect CKD </li></ul></ul><ul><ul><li>Prevent progression of CKD </li></ul></ul><ul><ul><li>Diagnosis and treat CVD </li></ul></ul><ul><ul><li>Treat co-morbid conditions and complications </li></ul></ul><ul><ul><li>Refer to nephrology : Emphasize role of the non-nephrologist MD in CKD care </li></ul></ul>Jan 23 2009 12:30 PM Collaborative Care of CKD
  51. 51. Teamwork in CKD Care Jan 23 2009 12:30 PM Collaborative Care of CKD Cardiologist PCP Dietician Nephrologist Patient Nurses and other health care professionals
  52. 52. Associated Systemic Complications in Chronic Kidney Disease (CKD) <ul><li>Anemia of CKD </li></ul><ul><li>Hypertension </li></ul><ul><li>Cardiovascular disease </li></ul><ul><li>Dyslipidemia </li></ul><ul><li>Osteodystrophy </li></ul><ul><li>Metabolic acidosis </li></ul><ul><li>Malnutrition </li></ul><ul><li>Diabetes mellitus </li></ul>Jan 23 2009 12:30 PM Collaborative Care of CKD Chronic Kidney Disease in USA Zabetakis. Am J Kidney Dis. 2000;36(suppl 3):S31.
  53. 53. Work-up of Anemia of CKD: When? <ul><li>Normal </li></ul><ul><ul><li>12 – 14 Hb g/dL (Hct 36-42) </li></ul></ul><ul><li>Anemia </li></ul><ul><ul><li>Men, Postmenopausal women </li></ul></ul><ul><ul><li>≤ 12 Hb g/dL (Hct < 36) </li></ul></ul><ul><ul><li>premenopausal women </li></ul></ul><ul><ul><li> ≤ 11.0 Hb g/dL </li></ul></ul>Jan 23 2009 12:30 PM Collaborative Care of CKD NKF. Am J Kidney Dis. 2001;37:S182. Guideline 1
  54. 54. Erythropoiesis in CKD Jan 23 2009 12:30 PM Collaborative Care of CKD <ul><ul><ul><li>Adapted from : Fauci. Harrison’s Principles of Internal Medicine. 1998:334. </li></ul></ul></ul>Red blood cells O 2 delivery Erythropoietin Erythroid marrow Iron RE cells RE=reticuloendothelial X
  55. 55. Anemia of CKD <ul><li>Primary cause: deficiency of erythropoietin </li></ul><ul><li>(absolute or relative) </li></ul><ul><li>Iron Deficiency (contributory) </li></ul><ul><li>Normocytic, normochromic anemia </li></ul><ul><li>usually starts when the GFR < 60 (Stage 3) </li></ul>Jan 23 2009 12:30 PM Collaborative Care of CKD
  56. 56. Evaluation of anemia of CKD <ul><li>assessment of other reasons for anemia </li></ul><ul><li>Iron stores, folate, and vitamin B12 levels </li></ul><ul><li>Others: blood loss, dysplastic disorders, malignancy, chronic inflammatory diseases, HIV </li></ul>Jan 23 2009 12:30 PM Collaborative Care of CKD
  57. 57. Assessment of Anemia In Renal Disease <ul><li>If GFR < 60 ml/min/1.73m 2 (Stage 3), consider anemia of renal origin </li></ul><ul><li>Folate </li></ul><ul><li>B12 </li></ul><ul><li>Iron, saturation, ferritin </li></ul><ul><li>R/O blood loss </li></ul><ul><li>Erythropoietin level (?) </li></ul><ul><li>R/O other chronic disease/inflammatory states </li></ul>Jan 23 2009 12:30 PM Collaborative Care of CKD
  58. 58. Evaluation of anemia of CKD <ul><li>Hemoglobin and/or hematocrit </li></ul><ul><li>Red blood cell indices </li></ul><ul><li>Reticulocyte count </li></ul><ul><li>Iron parameters </li></ul><ul><ul><li>Serum iron </li></ul></ul><ul><ul><li>Total iron-binding capacity (TIBC) </li></ul></ul><ul><ul><li>Percent transferrin saturation (TSAT) </li></ul></ul><ul><ul><li>Serum ferritin </li></ul></ul><ul><li>Test for occult blood in stool </li></ul>Jan 23 2009 12:30 PM Collaborative Care of CKD NKF. Am J Kidney Dis. 2001;37:S182 . Guideline 2
  59. 59. Clinical Consequences: untreated Anemia of CKD <ul><li>Cardiovascular </li></ul><ul><ul><li>Left ventricular hypertrophy (LVH) </li></ul></ul><ul><ul><li>Precipitating factor for congestive heart failure (CHF) </li></ul></ul><ul><ul><li>Exacerbation of angina </li></ul></ul><ul><li>Reduced </li></ul><ul><ul><ul><ul><ul><li>Aerobic capacity </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Overall well-being </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Cognition </li></ul></ul></ul></ul></ul>Jan 23 2009 12:30 PM Collaborative Care of CKD Erslev. N Engl J Med. 1991;324:1339 .
  60. 60. Anemia and LVH Jan 23 2009 12:30 PM Collaborative Care of CKD Prevalence of LVH (% Patients) 0 10 20 30 40 50 >50 35 – 49 25 – 34 <25 14.1 13.2 12.5 11.4 † * Ccr (mL/min) Mean Hb (g/dL) * P< 0.001 † P< 0.0001 Levin. Nephrol Dial Transplant. 2001;16(suppl 2):7.
  61. 61. LVH in CKD <ul><li>LVH is an independent predictor of cardiac death. </li></ul><ul><li>Hypertension, anemia, and diabetes are modifiable predictors of LVH. </li></ul><ul><ul><li>Blood pressure increase of 5 mm Hg is associated with 3% increase in LVH risk. </li></ul></ul><ul><ul><li>Hb decrease of 1 g/dL is associated with 6% increase in LVH risk. </li></ul></ul>Jan 23 2009 12:30 PM Collaborative Care of CKD Greaves . Am J Kidney Dis. 1994;24:768. Levin. Am J Kidney Dis. 1996;27:347. Foley RN et al. Kidney International. 1995;47: 186-192. Levin A et al. Am J Kidney Dis . 1996;27:347-354.
  62. 62. Impact: Anemia of CKD on Outcomes Jan 23 2009 12:30 PM Collaborative Care of CKD Chronic Kidney Disease in USACPMPM= cost per member per month Collins. Satellite Symposium.ASN, 2000. J Am Soc Nephrol 12: 2465–2473, 2001 Clinical and Economic Outcomes by Hematocrit Level: Incident ESRD Patients 1996 –1998 <30 30 to <33 33 to <36 36 to <39  39 0.0 0.5 1.0 1.5 2.0 Relative Ratio 8760 24,465 28,674 4307 555 n reference Mortality Hospital Cost PMPM Hct
  63. 63. Treatment: Anemia of CKD <ul><li>Recombinant erythropoietin </li></ul><ul><ul><li>Epoetin alfa </li></ul></ul><ul><ul><li>Darbepoetin </li></ul></ul><ul><li>Iron therapy prn </li></ul><ul><li>Red-blood-cell transfusion </li></ul><ul><ul><li>severe anemia </li></ul></ul><ul><ul><li>acute anemia </li></ul></ul>Jan 23 2009 12:30 PM Collaborative Care of CKD
  64. 64. Epoetin and Management of Anemia <ul><li>NKF-K/DOQI Guidelines </li></ul><ul><li>Target Hct 33%–36% (Hb 11–12 g/dL)* </li></ul><ul><li>Supplement with iron to maintain target Hct/Hb </li></ul><ul><li>Initiate epoetin alfa (or darbopoetin) </li></ul>Jan 23 2009 12:30 PM Collaborative Care of CKD NKF. Am J Kidney Dis. 2001;37(suppl 1):S182 .
  65. 65. Erythropoietin Treatment <ul><li>Epoetin is administered weekly in an incremental dose that commonly starts from 50-100units/kg SQ </li></ul><ul><li>Rate of rise of Hgb/Hct should be monitored weekly until the patient's condition is stable </li></ul><ul><li>hypertension, seizures, and venous thrombosis can occur when it rises too rapidly </li></ul>Jan 23 2009 12:30 PM Collaborative Care of CKD
  66. 66. Epoetin Management: Monitoring <ul><li>Starting dose 50–100 U/kg IV or SC qW (‘tiw’) </li></ul><ul><li>Ensure good blood pressure control </li></ul><ul><li>Adjusting the dose </li></ul><ul><ul><li>Reduce as Hct approaches 36% or increases by >4 points in 2 weeks </li></ul></ul><ul><ul><li>Increase incrementally if Hct does not increase by 5–6 points in 8 weeks (with adequate iron stores) </li></ul></ul><ul><li>Following a dosage adjustment: </li></ul><ul><li>Measure Hct twice weekly for at least 2–6 weeks until stable </li></ul>Jan 23 2009 12:30 PM Collaborative Care of CKD Chronic Kidney Disease in USA
  67. 67. Correction of anemia of CKD: many positive effects <ul><li>Improved/increased </li></ul><ul><li>energy, physical strength, appetite, and sleep </li></ul><ul><li>improved sex life, home life, and mood </li></ul><ul><li>improvement in vascular resistance </li></ul><ul><li>better immune responsiveness to antigenic stimuli </li></ul><ul><li>improved cognition </li></ul><ul><li>Decreased </li></ul><ul><li>shortness of breath </li></ul><ul><li>stabilization of left ventricular hypertrophy and possibly regression </li></ul><ul><li>decreased development of left ventricular dilatation </li></ul><ul><li>a decrease in high cardiac output </li></ul><ul><li>hospitalization rate, length of stay, and cost. </li></ul>Jan 23 2009 12:30 PM Collaborative Care of CKD
  68. 68. Jan 23 2009 12:30 PM Collaborative Care of CKD Epoetin Improves Health-Related Quality-of-Life Scores For all scales, scores have been scaled to a 0- to 100-point scale. Positive change indicates improved quality of life. P values not adjusted for multiple comparisons. * Significant change from baseline, P <0.05 †  P <0.10 10 8 6 4 2 0 -2 -4 -6 Energy Physical Function Role Function Home Management Alertness Behavior Social Interaction Depression Health Distress Life Satisfaction Sexual Dysfunction Mean Improvement From Baseline 5.8 7.8 1.7 6.1 8.8 4.4 1.0 3.4 1.4 3.0 0.5 -2.4 0 -2.5 -2.6 0.1 -0.1 0 -4.8 -3.1 * * * * * * † Revicki. Am J Kidney Dis . 1995;25:548. † Epoetin alfa Treated Control Group
  69. 69. Jan 23 2009 12:30 PM Collaborative Care of CKD Adapted from NKF. Am J Kidney Dis. 2001;37(suppl 1):S182. Anemia of CKD: Screening Fe Normal Workup SCr ≥2.0 CKD Stage 3 Hb Low? Yes Treat with medication as Indicated Fe Deficiency Treat with Iron Adequate Response? Yes Periodic Follow-up Anemia Corrected? Hematology Work-up Yes No No Adjust dose and iron Adequate Response? No
  70. 70. Current Care of Anemia in Patients With CKD is Sub-optimal <ul><li>Mean Hct at start of dialysis: 29%* </li></ul><ul><li>Only 28% of patients with CKD receive epoetin alfa before dialysis. </li></ul>Jan 23 2009 12:30 PM Collaborative Care of CKD Kausz. Am J Kidney Dis . 2000;36(suppl 3):S39. St. Peter. American Society of Nephrology Meeting. 2000:A0889. * Patients not treated with epoetin alfa.
  71. 71. Data to Support Ideal Hemoglobin Target (1): Normal hematocrit (hemodialysis) CHOIR (pre-dialysis) 10 14 11.3 13.5 ↓ morbidity/mortality ↑ morbidity/mortality ? Observational data, by association only ↓ morbidity/mortality ↑ morbidity/mortality
  72. 72. “ Epo Resistance” Poor response to Epoetin Rx <ul><li>Fe deficiency </li></ul><ul><li>Fe deficiency </li></ul><ul><li>Fe deficiency </li></ul><ul><li>Chronic inflammatory states </li></ul><ul><li>Severe hyperparathyroidism </li></ul><ul><li>Poor (inadequate) dialysis </li></ul><ul><li>Multisystem dysfunction (hematological, neurological, cardiac, immunological etc) </li></ul><ul><li>Iron deficiency </li></ul>Jan 23 2009 12:30 PM Collaborative Care of CKD
  73. 73. <ul><ul><li>Poor nutrition </li></ul></ul><ul><ul><li>Blood loss </li></ul></ul><ul><li>Increased iron needs </li></ul>Iron Deficiency in CKD Jan 23 2009 12:30 PM Collaborative Care of CKD NKF. Am J Kidney Dis. 2001;37(suppl 1):S182. Iron Deficiency With Epoetin alfa Preexisting Iron Deficiency
  74. 74. Assessment of Iron Status Jan 23 2009 12:30 PM Collaborative Care of CKD NKF. Am J Kidney Dis. 2001;37(suppl 1):S182. Macdougall. Curr Opin Hematol . 1999;6:121. Goodnough. Blood . 2000;96:823. <ul><li>Frequently used tests </li></ul><ul><li>Serum ferritin > 100 ng/mL </li></ul><ul><li>Transferrin saturation > 20% </li></ul><ul><li>Additional measurements </li></ul><ul><li>Reticulocyte Hb content </li></ul><ul><li>% Hypochromic RBCs </li></ul><ul><li>Erythrocyte ferritin </li></ul>Target
  75. 75. Administration of IV Iron: Dosage Jan 23 2009 12:30 PM Collaborative Care of CKD 100 mg 125 mg 1000 mg Maximum Single Dose 100 mg x 10 doses 125 mg x 8 doses 100 mg x 10 doses Recommended Dosage Iron sucrose Iron gluconate Iron dextran Iron Compound NKF. Am J Kidney Dis. 2001;37(suppl 1):S182. Van Wyck. Am J Kidney Dis. 2000;36:88. <ul><li>1 gram iron required to </li></ul><ul><ul><li>Increase Hct from 25% to 35% </li></ul></ul><ul><ul><li>Maintain iron stores over 3-month period </li></ul></ul><ul><li>Recommended dose:  1 gram </li></ul>
  76. 76. Administration of IV Iron: Safety <ul><li>Adverse Events Reported </li></ul><ul><li>Hypotension </li></ul><ul><li>Nausea, diarrhea, vomiting, headache, fever </li></ul><ul><li>Hypersensitivity reactions (anaphylaxis) </li></ul><ul><li>Increased infectious complications </li></ul>Jan 23 2009 12:30 PM Collaborative Care of CKD Bailie. Am J Kidney Dis . 2000;35:1. Collins. J Am Soc Nephrol. 1997;8:190A .
  77. 77. Possible Inadequacy of Oral Iron <ul><li>Low intestinal absorption of oral iron, even in healthy persons </li></ul><ul><li>Poor patient adherence </li></ul><ul><li>Intravenous iron has improved anemia in CKD and ESRD when oral iron has failed. </li></ul>Jan 23 2009 12:30 PM Collaborative Care of CKD NKF. Am J Kidney Dis . 2001;37(suppl 1):S182. Silverberg. Kidney Int . 1999;55(suppl 69):S79.
  78. 78. Iron Therapy: Summary <ul><li>Likely need for iron during Epoetin therapy </li></ul><ul><li>Oral iron </li></ul><ul><ul><li>Ease of administration </li></ul></ul><ul><ul><li>Safe </li></ul></ul><ul><ul><li>Possibly ineffective </li></ul></ul><ul><li>IV iron </li></ul><ul><ul><li>Less convenient administration </li></ul></ul><ul><ul><li>Safety concerns </li></ul></ul><ul><ul><li>More costly than oral iron </li></ul></ul><ul><ul><li>Effective </li></ul></ul>Jan 23 2009 12:30 PM Collaborative Care of CKD
  79. 79. Management: “Epo Resistance” Inadequate Correction of Anemia Jan 23 2009 12:30 PM Collaborative Care of CKD NKF. Am J Kidney Dis. 2001;37(suppl 1):S182. Macdougall. Curr Opin Hematol . 1999;6:121. Check iron status <ul><li>Infection and inflammation </li></ul><ul><li>Osteitis fibrosa </li></ul><ul><li>Chronic blood loss </li></ul><ul><li>Other causes of anemia </li></ul>Possible adjuvant therapies Consult hematologist Optimize dose Of Epoetin alfa Assess other causes <ul><li>Ascorbic acid </li></ul><ul><li>L-carnitine </li></ul><ul><li>Folic acid </li></ul><ul><li>Vitamin D </li></ul><ul><li>Vitamin B 12 </li></ul>
  80. 80. Associated Systemic Complications in Chronic Kidney Disease (CKD) <ul><li>Anemia of CKD </li></ul><ul><li>Hypertension </li></ul><ul><li>Cardiovascular disease </li></ul><ul><li>Dyslipidemia </li></ul><ul><li>Osteodystrophy </li></ul><ul><li>Metabolic acidosis </li></ul><ul><li>Malnutrition </li></ul><ul><li>Diabetes mellitus </li></ul>Jan 23 2009 12:30 PM Collaborative Care of CKD Chronic Kidney Disease in USA Zabetakis. Am J Kidney Dis. 2000;36(suppl 3):S31.
  81. 81. Hypertension and CKD Jan 23 2009 12:30 PM Collaborative Care of CKD CKD Hypertension Zabetakis. Am J Kidney Dis. 2000;36(suppl 3):S31.
  82. 82. Blood Pressure Is Poorly Controlled in CKD Jan 23 2009 12:30 PM Collaborative Care of CKD Coresh. Arch Intern Med . 2001;161:1207.  130/85 mm Hg 11% 27% 62%  140/90 mm Hg  140/90 mm Hg
  83. 83. Benefits of BP Control in CKD <ul><li> Rate of progression of kidney disease, especially in patients with diabetes </li></ul><ul><li> Cardiovascular complications </li></ul>Jan 23 2009 12:30 PM Collaborative Care of CKD Chronic Kidney Disease in USA Zabetakis. Am J Kidney Dis. 2000;36(suppl 3):S31.
  84. 84. HTN: Goal Blood Pressure Control Jan 23 2009 12:30 PM Collaborative Care of CKD JNC VII. JAMA 2003;289:2560. 140/90 mm Hg 130/80 mm Hg Without CKD With CKD
  85. 85. Blood Pressure Control in CKD: Goals Jan 23 2009 12:30 PM Collaborative Care of CKD JNC VI. Arch Intern Med. 1997;157:2413. 130/85 mm Hg 125/75 mm Hg Without Proteinuria With Proteinuria
  86. 86. BP Control: Interventions <ul><li>ACE inhibitors </li></ul><ul><li>Angiotensin-receptor blockers (ARBs) </li></ul><ul><li>Calcium channel blockers (CCBs) </li></ul><ul><li>Diuretics </li></ul><ul><li>Low-sodium diet </li></ul><ul><li>Combination therapy </li></ul>Jan 23 2009 12:30 PM Collaborative Care of CKD Del Vecchio. J Nephrol. 2001;14:7. JNC VI. Arch Intern Med. 1997;157:2413.
  87. 87. ACE Inhibitors Recommended for Slowing the Progression of CKD <ul><li>Unless contraindicated, patients with hypertension who have CKD should receive an ACE inhibitor to control hypertension and to slow progressive renal failure </li></ul>Jan 23 2009 12:30 PM Collaborative Care of CKD JNC VI. Arch Intern Med . 1997;157:2413.
  88. 88. Effect of Lisinopril on Progression of CKD Jan 23 2009 12:30 PM Collaborative Care of CKD Cinotti. Nephrol Dial Transplant. 2001;16:961. Prospective, multicenter, randomized trial Lisinopril (n=66) Alternative therapy (n=65) Measured change in GFR after 2 years Nondiabetic CKD
  89. 89. Effect of Lisinopril on Progression of CKD (cont’d) Jan 23 2009 12:30 PM Collaborative Care of CKD Conventional 0 12 24 Months 40 35 30 25 20 GFR mL/min/1.73 m 2 Lisinopril 18 66 65 58 60 56 54 53 55 Cinotti. Nephrol Dial Transplant. 2001;16:961 .
  90. 90. Associated Systemic Complications in Chronic Kidney Disease (CKD) <ul><li>Anemia of CKD </li></ul><ul><li>Hypertension </li></ul><ul><li>Cardiovascular disease </li></ul><ul><li>Dyslipidemia </li></ul><ul><li>Osteodystrophy </li></ul><ul><li>Metabolic acidosis </li></ul><ul><li>Malnutrition </li></ul><ul><li>Diabetes mellitus </li></ul>Jan 23 2009 12:30 PM Collaborative Care of CKD Chronic Kidney Disease in USA Zabetakis. Am J Kidney Dis. 2000;36(suppl 3):S31.
  91. 91. 2 ° Hyperparathyroidism: Natural History Jan 23 2009 12:30 PM Collaborative Care of CKD <ul><li>Multisystemic Toxicity </li></ul><ul><li>nervous system </li></ul><ul><li>cardiac </li></ul><ul><li>endocrine </li></ul><ul><li>immunologic </li></ul><ul><li>cutaneous </li></ul><ul><li>Bone Disease </li></ul><ul><li>osteitis fibrosa </li></ul><ul><li>demineralization </li></ul><ul><li>fractures </li></ul><ul><li>bone pain </li></ul> Calcium  1,25 Vit D  Phos Chronic Kidney Disease  PTH  PTH
  92. 92. Jan 23 2009 12:30 PM Collaborative Care of CKD Renal Osteodystrophy: Full Spectrum Adynamic bone Osteomalacia Normal Mild Osteitis fibrosa Mixed Hyperparathyroidism Calcium, calcitriol Aluminium Low bone turnover High bone turnover PTH ALP PTHALPP
  93. 93. Elevated PTH: Multisystemic Toxicity <ul><li>Widespread systemic effects </li></ul><ul><li>Insidious effects </li></ul><ul><li>Early Diagnosis & Rx needed </li></ul>Jan 23 2009 12:30 PM Collaborative Care of CKD * Bro AJKD November, 1997 PTH Bone Remodeling Red Blood Cell Production Cardiac Function Neurological Function Ca, P
  94. 94. Toxicity of PTH <ul><li>High turnover lesions </li></ul><ul><li>Osteitis Fibrosa </li></ul><ul><li>Brown Tumors </li></ul><ul><li>Bone Pain </li></ul><ul><li>Osteopenia </li></ul><ul><li>Fractures </li></ul><ul><li>Hypercalcemia </li></ul><ul><li>Hyperphosphatemia </li></ul><ul><li>Calcipylaxis </li></ul><ul><li>Nervous System </li></ul><ul><ul><li>neuropathy </li></ul></ul><ul><li>Heart </li></ul><ul><ul><li>Hypertension </li></ul></ul><ul><ul><li>LVH, interstitial fibrosis </li></ul></ul><ul><ul><li>Myocardial/valvular calcification </li></ul></ul><ul><li>Glucose Intolerance </li></ul><ul><li>Hyperlipidemia </li></ul><ul><li>Anemia </li></ul>Jan 23 2009 12:30 PM Collaborative Care of CKD Skeletal Extra-Skeletal Cunningham, J. Seminars in Dialysis, 13 (5) 2000
  95. 95. Long-Term Consequences of Secondary Hyperparathyroidism <ul><li>Osteitis fibrosa </li></ul><ul><li>Vascular calcification </li></ul><ul><li>Soft tissue calcification </li></ul><ul><li>Calciphylaxis </li></ul><ul><li>Resistance to vitamin D therapy </li></ul><ul><li>Need for parathyroidectomy </li></ul><ul><li>EPO resistance </li></ul>Jan 23 2009 12:30 PM Collaborative Care of CKD
  96. 96. PTH levels & Relative Risk of Death Jan 23 2009 12:30 PM Collaborative Care of CKD pg/mL Chertow ASN 2000
  97. 97. Jan 23 2009 12:30 PM Collaborative Care of CKD <ul><ul><ul><ul><ul><li>Block GA, Am J Kidney Dis. 1998;31:607-617. </li></ul></ul></ul></ul></ul>Higher Phosphorus: Higher Mortality Risk p=0.03 p=0.0001 n = 6407
  98. 98. Jan 23 2009 12:30 PM Collaborative Care of CKD Higher Ca  P Product: Higher Mortality Risk <ul><ul><ul><ul><ul><li>Block GA, et al. Am J Kidney Dis. 1998;31:607-617. </li></ul></ul></ul></ul></ul>p=0.01 n = 2669
  99. 99. Jan 23 2009 12:30 PM Collaborative Care of CKD Llach, et al. AJKD, 32,4 Supp2, 1998:S3-12 GFR, ml/m Calcitriol, pg/ml 15 25 35 45 55 65 75 85 95 105 Intact PTH, pg/ml 100 200 300 400 CALCITRIOL PTH P <0.01 P <0.01 When does Renal Osteodystrophy start? Calcitriol & PTH at Various Stages of CKD 0 10 20 30 40 50 n = 150
  100. 100. Renal Osteodystrophy: CKD 3&4 Jan 23 2009 12:30 PM Collaborative Care of CKD Phosphate retention Calcitriol Deficiency Hypocalcemia 2 º Hyperparathyroidism Chronic Kidney Disease
  101. 101. Phosphorus Retention/Vitamin D Deficiency <ul><li>Phosphorus retention should be treated by dietary phosphorus restriction and phosphate binders </li></ul><ul><li>Vitamin D deficiency leads to  calcium absorption </li></ul><ul><li>Vitamin D supplements recommended for hypocalcemia, provided phosphorus levels are normal </li></ul><ul><li>Vitamin D supplements decrease bone pain and lessen bone pathology </li></ul>Jan 23 2009 12:30 PM Collaborative Care of CKD Bailey JL, Mitch WE. In: Brady HR, Wilcox CS. Therapy in Nephrology and Hypertension . 1999:474-479. Delmez JA, Slatopolsky E. In: Brady HR, Wilcox CS. Therapy in Nephrology and Hypertension . 1999:497-504.
  102. 102. Metabolic Acidosis <ul><li>Occurs in all patients, usually when GFR < 30 ml/min (Stage 4 CKD) </li></ul><ul><li>Consequences: </li></ul><ul><ul><li>Increased muscle catabolism </li></ul></ul><ul><ul><li>Potentiates metabolic bone disease </li></ul></ul><ul><li>Treatment: NaHCO 3 or NaCitrate </li></ul>Jan 23 2009 12:30 PM Collaborative Care of CKD Bailey JL, Mitch WE. In: Brady HR, Wilcox CS. Therapy in Nephrology and Hypertension . 1999:474-479.
  103. 103. Renal Osteodystrophy: Management <ul><li>↓ P diet (.8-1g/d)+Fix acidosis:HCO 3 >22 mmol/L </li></ul><ul><li>Binders: P>5mg/dl: (CaCO 3 , Ca Acetate, Sevelamer) taken with meals </li></ul><ul><li>1,25 Vitamin D for low Ca + nl P (when iPTH>250 pg/mL) </li></ul><ul><li>Rx: calcitriol 0.25 µ g/d; doxercalciferol 2.5 µ g/3-7d/wk. Target iPTH 80-300(10-65 pg/mL ) </li></ul>Jan 23 2009 12:30 PM Collaborative Care of CKD
  104. 104. CKD stages 3&4: Acid-Base <ul><li>Monitor serum bicarbonate acidosis: </li></ul><ul><li>HCO 3 >22 mmol/L </li></ul><ul><li>Dietary protein </li></ul><ul><li>Na Bicarbonate tablets or Na Acetate </li></ul>Jan 23 2009 12:30 PM Collaborative Care of CKD
  105. 105. Management: R enal Osteodystrophy <ul><li>Control serum phosphorus (3.0-5.0 mg/dL) </li></ul><ul><li>Prevent or reverse accumulation of trace substances i.e., aluminum, calcium, etc. </li></ul><ul><li>Maintain serum calcium within normal limits (8.5-9.6 mg/dL) </li></ul><ul><li>Suppress secondary hyperparathyroidism using vit D or analogs </li></ul><ul><li>Prevent the development of parathyroid hyperplasia </li></ul><ul><li>Avoid over suppression of PTH (adyn bone dx) </li></ul>Jan 23 2009 12:30 PM Collaborative Care of CKD
  106. 106. Target Values <ul><li>Phosphorus: 3.0 - 5.0 mg/dL – ideal </li></ul><ul><li>Calcium: normal range ( 8.5-9.6 mg/dL) </li></ul><ul><li>Ca X P: < 55 </li></ul><ul><li>PTH: 150 - 300 pg/ml </li></ul>Jan 23 2009 12:30 PM Collaborative Care of CKD
  107. 107. Associated Systemic Complications in Chronic Kidney Disease (CKD) <ul><li>Anemia of CKD </li></ul><ul><li>Hypertension </li></ul><ul><li>Cardiovascular disease </li></ul><ul><li>Dyslipidemia </li></ul><ul><li>Osteodystrophy </li></ul><ul><li>Metabolic acidosis </li></ul><ul><li>Malnutrition </li></ul><ul><li>Diabetes mellitus </li></ul>Jan 23 2009 12:30 PM Collaborative Care of CKD Chronic Kidney Disease in USA Zabetakis. Am J Kidney Dis. 2000;36(suppl 3):S31.
  108. 108. CKD stages 3&4: N utrition <ul><li>Dietary Restrictions/ Nutritional counseling </li></ul><ul><li>Lifestyle/dietary modification </li></ul><ul><li>Na: 2g/d </li></ul><ul><li>K: 2g/d </li></ul><ul><li>Phos: 1g/d </li></ul><ul><li>Protein: 0.6-0.8 gm/kg , avoid ↓ albumin </li></ul><ul><li>30-35 kcal/kg body weight </li></ul>Jan 23 2009 12:30 PM Collaborative Care of CKD
  109. 109. HYPERLIPIDEMIA <ul><li>CKD classified as high risk, ATPIII </li></ul><ul><li>Yearly or more frequent lipid profile per GFR and Rx </li></ul><ul><li>LDL target < 100 mg/dl </li></ul><ul><li>Lifestyle modification </li></ul><ul><li>Statins first line </li></ul><ul><li>Avoid toxic combinations: fibrate + statins </li></ul><ul><li>Fibrates: renal excretion: eg gemfibrozil </li></ul>Jan 23 2009 12:30 PM Collaborative Care of CKD
  110. 110. Eating Well and Exercise <ul><li>Protein malnutrition is common in CKD. </li></ul><ul><li>Consider dietary protein restriction </li></ul><ul><ul><li>Properly monitored by experienced dietitian and nephrologist </li></ul></ul><ul><ul><ul><li> Complications of uremia </li></ul></ul></ul><ul><ul><ul><li> Rate of loss of renal function </li></ul></ul></ul><ul><ul><li>May improve long-term survival of patient </li></ul></ul><ul><li>Exercise </li></ul><ul><ul><li>Improves physical functioning </li></ul></ul><ul><ul><li>Improves cardiovascular health </li></ul></ul>Jan 23 2009 12:30 PM Collaborative Care of CKD Bailey. In: Brady, ed. Therapy in Nephrology and Hypertension . 1999:474. NKF. Staying Fit With Kidney Disease.
  111. 111. Associated Systemic Complications in Chronic Kidney Disease (CKD) <ul><li>Anemia of CKD </li></ul><ul><li>Hypertension </li></ul><ul><li>Cardiovascular disease </li></ul><ul><li>Dyslipidemia </li></ul><ul><li>Osteodystrophy </li></ul><ul><li>Metabolic acidosis </li></ul><ul><li>Malnutrition </li></ul><ul><li>Diabetes mellitus </li></ul>Jan 23 2009 12:30 PM Collaborative Care of CKD Chronic Kidney Disease in USA Zabetakis. Am J Kidney Dis. 2000;36(suppl 3):S31.
  112. 112. Diabetes: The Most Common Cause of ESRD Jan 23 2009 12:30 PM Collaborative Care of CKD Primary Diagnosis for Patients Who Start Dialysis USRDS. Annual data report. 2000:259. Glomerulonephritis 12.6% Other 17.2% Diabetes 43.7% Hypertension 26.5%
  113. 113. Pathogenesis of Diabetic Nephropathy <ul><li>Early stage </li></ul><ul><ul><li>Renal and glomerular hypertrophy </li></ul></ul><ul><ul><li>Hyperfiltration </li></ul></ul><ul><li>Established stage </li></ul><ul><ul><li>GBM thickening </li></ul></ul><ul><ul><li>Mesangial matrix expansion </li></ul></ul><ul><ul><li> albumin excretion rate </li></ul></ul>Jan 23 2009 12:30 PM Collaborative Care of CKD McGowan. Clin Lab Med . 2001;21:111. GBM=glomerular basement membrane
  114. 114. Pathogenesis of Diabetic Nephropathy <ul><li>Advanced stage </li></ul><ul><ul><li>Nodular glomerulosclerosis </li></ul></ul><ul><ul><li>Arteriolar hyalinosis </li></ul></ul><ul><ul><li>Tubulointerstitial fibrosis </li></ul></ul><ul><ul><li>Hypertension </li></ul></ul><ul><ul><li>Proteinuria </li></ul></ul><ul><ul><li> renal function </li></ul></ul>Jan 23 2009 12:30 PM Collaborative Care of CKD McGowan. Clin Lab Med . 2001;21:111.
  115. 115. Albuminuria Jan 23 2009 12:30 PM Collaborative Care of CKD ADA. Diabetes Care . 2001;24(suppl 1):S69.  300  200  300 Clinical albuminuria 30–299 20–199 30–299 Microalbum-inuria  30  20  30 Normal Spot collection (mcg/mg creat) Timed collection (mcg/min) 24-h collection (mg/24 h) Category
  116. 116. Recommended Screening Tests for Renal Complications <ul><li>Serum creatinine </li></ul><ul><li>Urinalysis </li></ul><ul><ul><li>Spot collection </li></ul></ul><ul><ul><li>24-hour collection with creatinine </li></ul></ul><ul><ul><li>Timed collection </li></ul></ul>Jan 23 2009 12:30 PM Collaborative Care of CKD McCarthy. Mayo Clin Proc. 1999;74:269. ADA. Diabetes Care. 2001;24(suppl 1):S33.
  117. 117. Recommended Screening Tests for Renal Complications <ul><li>If protein is negative on urinalysis: </li></ul><ul><li>Random, spot urine for albuminuria </li></ul><ul><li>Positive if >30 mg/g* or ratio >0.03 </li></ul><ul><li>Repeat 2 – 3 times over 6 months, or confirm with 24-hour collection for microalbumin </li></ul>Jan 23 2009 12:30 PM Collaborative Care of CKD * >30 (mg) albumin/ (g) creatinine ADA. Diabetes Care . 2001;24(suppl 1):S69.
  118. 118. Hypertension and Diabetic Nephropathy <ul><li>Important to progression of diabetic nephropathy </li></ul><ul><li>In type 1 diabetes </li></ul><ul><ul><li>Primarily caused by nephropathy </li></ul></ul><ul><ul><li>Manifests concurrently with microalbuminuria </li></ul></ul><ul><li>In type 2 diabetes </li></ul><ul><ul><li>Present in about one third at diagnosis </li></ul></ul><ul><ul><li>Coexists with numerous other cardiovascular comorbidities </li></ul></ul>Jan 23 2009 12:30 PM Collaborative Care of CKD ADA. Diabetes Care . 2001;24(suppl 1):S69. Ritz. J Intern Med . 2001;249:215.
  119. 119. Effect of Blood Pressure on Progression of Nephropathy* Jan 23 2009 12:30 PM Collaborative Care of CKD 95 98 101 104 107 110 113 116 119 r = 0.69; P <0.05 MAP (mm Hg) GFR (mL/min/year) 130/85 140/90 Untreated HTN 0 -2 -4 -6 -8 -10 -12 -14 Sheinfeld. Am J Hypertens. 1999;12:80S. Bakris. Diabetes Res Clin Pract . 1998;39(suppl):S39. *Summary of trials using ACE inhibitors to achieve target BP
  120. 120. Decreased Albuminuria and GFR Jan 23 2009 12:30 PM Collaborative Care of CKD Rossing. Diabetologia. 1994;37:511. r =0.73 P <0.001 15 10 5 0 -5 -100 -50 0 50 100 Relative change in albuminuria (%) Decline in GFR (mL/min/y)
  121. 121. BP Control and Proteinuria Jan 23 2009 12:30 PM Collaborative Care of CKD * P <0.05 vs patients with MAP  92 Lewis et al. Am J Kidney Dis . 1999;34:809.  92 92.1 –99.9 100–107 107.1 n 47 41 32 6 4882 (2878) 4292 (4754) 1830 (1701) 1073* (1535) Mean Total Proteinuria ( ± SD) (mg/24 h) Patients With Total Proteinuria <500 mg/24 h 27 2 11 0 MAP (mm Hg) Change in SCr (mg/dL) +0.14* +0.38 +0.38 +0.92 Change in GFR (mL/min) -5.2* -11.6 -6.2 -11.0
  122. 122. Jan 23 2009 12:30 PM Collaborative Care of CKD Adler. Br Med J. 2000;321:412. Stratton. Br Med J. 2000;321:405. Incidence* by Mean Systolic BP and HbA 1c Concentration 50 40 30 20 10 0 MI Microvascular end points Updated mean systolic BP (mm Hg) 110 120 130 140 150 160 170 Adjusted incidence/1000 person-y (%) Updated mean HbA 1c concentration (%) 80 60 40 20 0 5 6 7 8 9 10 11 Adjusted incidence/1000 person-y (%) MI Microvascular end points *of MI and microvascular end points (UKPDS)
  123. 123. Excess Mortality With Hypertension and Proteinuria Jan 23 2009 12:30 PM Collaborative Care of CKD Status of hypertension (H) and proteinuria (P) in type 2 diabetes Wang. Diabetes Care. 1996;19:305. 0 500 1000 Standardized mortality ratio P-H- P-H+ P+H- P+H+ P-H- P-H+ P+H- P+H+ Men Women
  124. 124. ACE Inhibitors Recommended for Patients With Diabetic Nephropathy <ul><li>In patients with diabetic nephropathy, ACE inhibitors are preferred. If ACE inhibitors are contraindicated or are not well tolerated, angiotensin II receptor blockers may be considered. </li></ul>Jan 23 2009 12:30 PM Collaborative Care of CKD JNC-VI. 1997. NIH Publication.
  125. 125. HOPE Trial: Study Design <ul><li>Double-blind, placebo-controlled study </li></ul><ul><ul><li>Ramipril: 10 mg/day </li></ul></ul><ul><li>9541 high-risk patients  55 years of age </li></ul><ul><ul><li>Evidence of vascular disease (including CHD), stroke, or peripheral vascular disease </li></ul></ul><ul><ul><li>or </li></ul></ul><ul><ul><li>Diabetes and one other coronary risk factor (serum total cholesterol  200 mg/dL, low serum HDL, hypertension, microalbuminuria, or smoking) </li></ul></ul><ul><li>3577 with diabetes </li></ul>Jan 23 2009 12:30 PM Collaborative Care of CKD HOPE. Lancet . 2000;355:253.
  126. 126. CV Outcomes and Renal Disease Jan 23 2009 12:30 PM Collaborative Care of CKD 14.4 9.3 5.8 10.3 2.5 18.5 14.8 9.4 12.5 4.5 0 2 4 6 8 10 12 14 16 18 20 Primary outcome † Total mortality CV mortality MI Hospitalization for CHF Ccr  65 mL/min (n=3394) Ccr >65 mL/min (n=5888) * * * * * Incidence (%) Mann. Ann Intern Med . 2001;134:629. * P <0.05 † Combined CV death, MI, or stroke
  127. 127. Effect of ACE Inhibitors on Renal Disease Progression <ul><li>Prospective, double-blind, randomized trial </li></ul><ul><ul><li>Captopril (n=207) 25 mg TID </li></ul></ul><ul><ul><li>Placebo (n=202) TID </li></ul></ul><ul><li>30 participating health-care centers </li></ul><ul><li>Inclusion criteria </li></ul><ul><ul><li>Insulin-dependent diabetes mellitus </li></ul></ul><ul><ul><ul><li>Onset before age 30 and  7 years with disease </li></ul></ul></ul><ul><ul><ul><li>Diabetic retinopathy </li></ul></ul></ul><ul><ul><li>Urinary protein excretion  500 mg/day </li></ul></ul><ul><ul><li>SCr  2.5 mg/dL </li></ul></ul><ul><ul><li>Ages 18 to 49 </li></ul></ul><ul><li>Primary endpoint: doubling of SCr to  2.0 mg/dL </li></ul>Jan 23 2009 12:30 PM Collaborative Care of CKD Lewis. N Engl J Med . 1993;329:1456.
  128. 128. Effect of ACE Inhibitors on Renal Disease Progression Jan 23 2009 12:30 PM Collaborative Care of CKD 0 5 10 15 20 25 30 35 40 45 50 *P =0.007 Lewis. N Engl J Med . 1993;329:1456. Primary End Point: Doubling of SCr Concentration 25* 43 Captopril Placebo # of Patients
  129. 129. Treatment of Diabetic Nephropathy <ul><li>Inclusion criteria </li></ul><ul><ul><li>30 to 75 years of age </li></ul></ul><ul><ul><li>Hypertensive (diastolic: 90 to 110 mm Hg) </li></ul></ul><ul><ul><li>Type 2 diabetes </li></ul></ul><ul><ul><li>Urinary albumin:creatinine ratio 2.5 to 25 mg/mmol) </li></ul></ul>Jan 23 2009 12:30 PM Collaborative Care of CKD ACEI and ARB Combination Therapy Mogensen. Br Med J. 2000;321:1440. <ul><li>Randomized, double-blind, double-dummy trial </li></ul><ul><ul><li>First 12 weeks </li></ul></ul><ul><ul><ul><li>Lisinopril: n = 98 </li></ul></ul></ul><ul><ul><ul><li>Candesartan: n = 99 </li></ul></ul></ul><ul><ul><li>Weeks 12 to 64 </li></ul></ul><ul><ul><ul><li>Lisinopril: n = 64 </li></ul></ul></ul><ul><ul><ul><li>Candesartan: n = 66 </li></ul></ul></ul><ul><ul><ul><li>Combination regimen: n = 67 </li></ul></ul></ul>ACEI=angiotensin-converting enzyme inhibitor
  130. 130. Treatment of Diabetic Nephropathy Jan 23 2009 12:30 PM Collaborative Care of CKD Chronic Kidney Disease in USAACEI = angiotensin-converting enzyme inhibitor ARB = angiotensin-II receptor blocker * P = 0.04 Mogensen. Br Med J. 2000;321:1440. ACEI and ARB Combination Therapy Mean Reduction in Urinary Albumin:Creatinine Ratio -60 -50 -40 -30 -20 -10 0 * % Reduction Lisinopril Candesartan Combination Regimen
  131. 131. Angiotensin-II Receptor Antagonists in Type 2 Diabetes <ul><li>Randomized, double-blind, placebo-controlled study </li></ul><ul><ul><li>Losartan (n=751): 50 to 100 mg/day </li></ul></ul><ul><ul><li>Placebo (n=762) </li></ul></ul><ul><li>Inclusion criteria </li></ul><ul><ul><li>Type 2 diabetes </li></ul></ul><ul><ul><li>Diabetic nephropathy </li></ul></ul><ul><ul><ul><li>SCr 1.3–3.0 mg/dL </li></ul></ul></ul><ul><ul><ul><li>Urinary albumin:creatinine ratio  300 </li></ul></ul></ul>Jan 23 2009 12:30 PM Collaborative Care of CKD The Reduction of Endpoints in Type 2 Diabetes with Angiotensin-II Antagonist Losartan trial (RENAAL) Brenner. N Engl J Med . 2001;345:861.
  132. 132. Angiotensin-II Receptor Antagonists in Type 2 Diabetes: RENAAL Jan 23 2009 12:30 PM Collaborative Care of CKD Brenner. N Engl J Med . 2001;345:861. * † ** * P =0.02 † P =0.006 ** P =0.002
  133. 133. Angiotensin-II Receptor Antagonists in Type 2 Diabetes <ul><li>Prospective, randomized, double-blind study </li></ul><ul><ul><li>Irbesartan (n=579): 300 mg/day </li></ul></ul><ul><ul><li>Amlodipine (n=567): 10 mg/day </li></ul></ul><ul><ul><li>Placebo (n=569) </li></ul></ul><ul><li>Inclusion criteria </li></ul><ul><ul><li>Type 2 diabetes </li></ul></ul><ul><ul><li>Hypertension </li></ul></ul><ul><ul><ul><li>Systolic:  135 mm Hg (sitting) </li></ul></ul></ul><ul><ul><ul><li>Diastolic:  85 mm Hg (sitting) </li></ul></ul></ul><ul><ul><ul><li>History of antihypertensive therapy </li></ul></ul></ul><ul><ul><li>Proteinuria </li></ul></ul><ul><ul><ul><li>SCr: 1.0 – 3.0 mg/dL (women) and 1.2 – 3.0 mg/dL (men) </li></ul></ul></ul><ul><ul><ul><li>Urine protein excretion: 900 mg/24-hours </li></ul></ul></ul>Jan 23 2009 12:30 PM Collaborative Care of CKD The Irbesartan Diabetic Nephropathy Trial (IDNT) Lewis. N Engl J Med . 2001;345:851.
  134. 134. Jan 23 2009 12:30 PM Collaborative Care of CKD Angiotensin-II Receptor Antagonists in Type 2 Diabetes: IDNT * P =0.006 † P =0.02 ** P  0.001 † † P =0.003 Lewis. N Engl J Med . 2001;345:851. 20 † 37** 33 †† 23 23 23* vs Amlodipine vs Placebo
  135. 135. Treatment of Diabetic Nephropathy <ul><li>Choice of antihypertensive agent </li></ul><ul><ul><li>ACEI and/or ARB </li></ul></ul><ul><ul><li>Diuretic </li></ul></ul><ul><ul><li>NCCB or beta blocker </li></ul></ul><ul><ul><li>Avoid dihydropyridine CCBs </li></ul></ul><ul><li>Target blood pressure </li></ul><ul><ul><li> 130/85 mm Hg </li></ul></ul>Jan 23 2009 12:30 PM Collaborative Care of CKD ADA. Diabetes Care . 2001;24(1):S69. NCCB= nondihydropyridine calcium-channel blocker
  136. 136. Nutritional Restrictions <ul><li>Sodium </li></ul><ul><ul><li>Hypertensive/nephropathy patients </li></ul></ul><ul><ul><ul><li> 2000 mg/day </li></ul></ul></ul><ul><li>Protein (controversial) </li></ul><ul><ul><li>Microalbuminuria: 0.8 g/kg/day </li></ul></ul><ul><ul><li>Decreasing GFR: 0.6 g/kg/day </li></ul></ul><ul><li>Alcohol </li></ul><ul><ul><li> 2 drinks/day (men) </li></ul></ul><ul><ul><li> 1 drink/day (women) </li></ul></ul><ul><li>Potassium </li></ul><ul><ul><li>Restricted if hyperkalemic </li></ul></ul>Jan 23 2009 12:30 PM Collaborative Care of CKD ADA. Diabetes Care . 2001;24(1):S44.
  137. 137. Dyslipidemia in Diabetic Nephropathy <ul><li>Increased CHD morbidity and mortality risk </li></ul><ul><ul><li> atherogenicity </li></ul></ul><ul><ul><li> triglycerides </li></ul></ul><ul><li>Abnormal lipid metabolism </li></ul><ul><ul><li>In patients with type 2 diabetes and nephropathy </li></ul></ul><ul><ul><ul><li> Hepatic triglyceride lipase (HGTL) </li></ul></ul></ul><ul><ul><ul><li> IDL and remnant-like particles (RLP) </li></ul></ul></ul><ul><ul><ul><li> LDL size </li></ul></ul></ul><ul><ul><ul><li> lipoprotein lipase mass </li></ul></ul></ul><ul><ul><ul><li> von Willebrand factor </li></ul></ul></ul>Jan 23 2009 12:30 PM Collaborative Care of CKD ADA. Diabetes Care . 2001;24(suppl 1):S58. Hirano . Kidney Int . 1999;56(suppl 71):S22.
  138. 138. Anemia in Diabetic Nephropathy <ul><li>Normochromic and normocytic </li></ul><ul><li>May occur early in patients with diabetic nephropathy </li></ul><ul><li>Related to deficiency in endogenous erythropoietin production </li></ul>Jan 23 2009 12:30 PM Collaborative Care of CKD Zabetakis. Am K Kidney Dis . 2000;36(6 Suppl 3):S31. Bosman . Diabetes Care . 2001;24:495.
  139. 139. Future Directions <ul><li>Role of ACE inhibitor/ARB combination therapy or ARB monotherapy in diabetic nephropathy </li></ul><ul><li>When to begin ACE inhibitor/ARB therapy </li></ul><ul><li>Renoprotective benefit of these agents independent of antihypertensive effects </li></ul><ul><li>Use of dihydropyridine vs nondihydropyridine calcium-channel blockers </li></ul><ul><li>Anemia in the patient with CKD caused by diabetes </li></ul>Jan 23 2009 12:30 PM Collaborative Care of CKD
  140. 140. CKD Predicts CVD Jan 23 2009 12:30 PM Collaborative Care of CKD Go, et al., 2004 Age-Standardized Rate of Cardiovascular Events (per 100 person-yr) Estimated GFR (mL/min/1.73 m2)
  141. 141. Cardiovascular Risk Intervention In CKD • Weight loss to < 120% ideal BW • Antiplatelet agents -bASA, ASA • Treat malnutrition • ACEi, ARB-post MI? • Exercise 30 min 3-5 x wk • Glucose control in DM • Smoking cessation • Treat LVH - BP, anemia • BP control - MAP < 92 • Homocysteine control - folic, B-vitamins • Lipid control • Diet modification  100 mEq sodium – LDL < 100 mg/dl  30% fat – HDL > 35 mg/dl < 7% saturated fat – TG < 200 mg/dl < 200 mg/dl cholesterol •  blockers • Omega-3 fatty acids • Antioxidants - vitamin E • Reduce proteinuria After JNC VI, Arch Intern Med 157:2413, 1997
  142. 142. Risk Factors: Development & Progression of CKD <ul><ul><ul><li>Hypertension </li></ul></ul></ul><ul><ul><ul><li>Diabetes </li></ul></ul></ul><ul><ul><ul><li>Tubulointerstitial disease </li></ul></ul></ul><ul><ul><ul><li>Atherosclerosis </li></ul></ul></ul><ul><ul><ul><li>Autoimmune disease </li></ul></ul></ul><ul><ul><ul><li>Anatomic abnormalities of the urogenital system </li></ul></ul></ul><ul><ul><ul><li>Renal allograft </li></ul></ul></ul><ul><ul><ul><li>Exposure to nephrotoxic agents </li></ul></ul></ul><ul><ul><ul><ul><li>NSAIDS, IVcontrast, drugs </li></ul></ul></ul></ul><ul><ul><ul><li>Hyperlipidemia </li></ul></ul></ul><ul><ul><ul><li>Tobacco abuse </li></ul></ul></ul><ul><ul><ul><li>Obesity </li></ul></ul></ul><ul><ul><ul><li>Renal calculi </li></ul></ul></ul>Jan 23 2009 12:30 PM Collaborative Care of CKD <ul><ul><ul><li>Family history of any type of process which can lead to CKD </li></ul></ul></ul><ul><ul><ul><li>Congenital renal disease </li></ul></ul></ul><ul><ul><ul><li>Other causes of decreased kidney mass </li></ul></ul></ul><ul><ul><ul><li>Age </li></ul></ul></ul><ul><ul><ul><li>Male gender </li></ul></ul></ul><ul><ul><ul><li>Non-Caucasian race </li></ul></ul></ul><ul><ul><ul><li>Renal cystic disease </li></ul></ul></ul><ul><ul><ul><li>Glomerular disease </li></ul></ul></ul>Modifiable Non-Modifiable Bolton
  143. 143. Risk Factors for CKD <ul><li>Diabetes </li></ul><ul><li>Hypertension </li></ul><ul><li>Age </li></ul><ul><li>Family history of kidney disease or diabetes </li></ul><ul><li>Male gender </li></ul><ul><li>Racial/Ethnic Background: </li></ul><ul><ul><li>African American, Native American, </li></ul></ul><ul><ul><li>Asian-American, </li></ul></ul><ul><ul><li>Pacific Islander, </li></ul></ul><ul><ul><li>Latin American </li></ul></ul><ul><li>Tobacco Use </li></ul>Jan 23 2009 12:30 PM Collaborative Care of CKD Chronic Kidney Disease in USA Bolton. Am J Kidney Dis. 2000;36(suppl 3):S4. US Renal Data System. USRDS 2000 Annual Report. NIH, June 2000. Pinto-Sietsma. Ann Intern Med . 2000;133:585.
  144. 144. Risk Factors for CKD (Cont.) <ul><li>Coexisting kidney disease </li></ul><ul><li>Anemia </li></ul><ul><li>High-protein diet </li></ul><ul><li>Hyperlipidemia </li></ul><ul><li>Atherosclerosis </li></ul><ul><li>Obesity </li></ul><ul><li>Exposure to nephrotoxic drugs </li></ul><ul><ul><li>NSAIDS </li></ul></ul><ul><ul><li>Contrast dye </li></ul></ul><ul><ul><li>Hydrocarbons </li></ul></ul>Jan 23 2009 12:30 PM Collaborative Care of CKD McCarthy. Mayo Clin Proc . 1999;74(3):269.
  145. 145. Recommended Screening Tests for Patients at Risk for CKD <ul><li>SCr </li></ul><ul><li>Blood pressure </li></ul><ul><li>Glucose </li></ul><ul><li>Urinalysis </li></ul><ul><li>Microalbuminuria/proteinuria </li></ul>Jan 23 2009 12:30 PM Collaborative Care of CKD McCarthy. Mayo Clin Proc . 1999;74:269. American Diabetes Association. Diabetes Care . 2000;23(suppl 1):32. Screening is the beginning of a complex management process for CKD.
  146. 146. Improving Upon SCr Screening <ul><li>Example: </li></ul><ul><ul><li>80-year-old woman, 50-kg body weight, 1.5 mg/dL SCr </li></ul></ul><ul><li>Formula result: </li></ul><ul><ul><li>Ccr= 24 mL/min Severe dysfunction </li></ul></ul>Jan 23 2009 12:30 PM Collaborative Care of CKD * For women ( x 1.0 for men) Cockcroft. Nephron . 1976;16:31. Cockcroft-Gault (C-G) Method for Estimating Ccr Ccr= (140 – age [y])(body wt [kg]) x 0.85*) (72)(SCr [mg/dL])
  147. 147. Screening for CKD: SCr vs Ccr <ul><li>Retrospective study of 2781 patients referred by community physicians </li></ul><ul><li>Patients grouped by </li></ul><ul><ul><li>SCr level abnormalities >1.2mg/dL </li></ul></ul><ul><ul><li>Significantly abnormal Cockcroft-Gault values  50mL/min </li></ul></ul>Jan 23 2009 12:30 PM Collaborative Care of CKD Duncan L. Neph Dial Transplant . 2001; 16: 1042-1046.
  148. 148. Optimal CKD Patient Care Jan 23 2009 12:30 PM Collaborative Care of CKD Early Detection of CKD Delay progression ACE inhibitors BP control Blood sugar control Protein restriction? Prevent complications Anemia Malnutrition Osteodystrophy Acidosis Treat co morbidities Cardiac disease Vascular disease Diabetes Prepare for RRT Educate patient Select RRT modality Create access and initiate dialysis in a timely fashion Adapted from Pereira. Kidney International. 2000;57:351.
  149. 149. Treatment of Metabolic Acidosis in CKD <ul><li>Goal </li></ul><ul><ul><li>Serum HCO 3 - > 20 mEq/L </li></ul></ul><ul><ul><li>pH > 7.35 </li></ul></ul><ul><li>Agents </li></ul><ul><ul><li>Sodium bicarbonate tablets </li></ul></ul><ul><ul><ul><li>(650 mg = ~8 mEq HCO3-) </li></ul></ul></ul><ul><ul><li>Sodium citrate (Shohl’s solution) </li></ul></ul><ul><li>Dose of HCO 3 - </li></ul><ul><ul><li>1.0-1.5 mEq/kg/day </li></ul></ul><ul><ul><li>Dependent upon initial serum HCO 3 - and degree of renal insufficiency </li></ul></ul>Jan 23 2009 12:30 PM Collaborative Care of CKD Dubose TD. Harrison’s Principles of Internal Medicine . 1998:277. Facts and Comparisons . 1977; 726-727.
  150. 150. Jan 23 2009 12:30 PM Collaborative Care of CKD Events in Chronic Kidney Disease © Copyright 2003 MedPoint Communications, Inc.
  151. 151. Vascular Access Ifudu NEJM 1998 (15) 339- Jan 23 2009 12:30 PM Collaborative Care of CKD Native Arteriovenous Fistula Needed for adequate hemodialysis CKD 3: No blood draws in non-dominant arm CKD 4: Maturation 8 wks+ Thrombosis and infection of the VA: 20-40% admissions PTFE Graft
  152. 152. Who Should be Treated for Chronic Kidney Disease? <ul><li>With diabetes : </li></ul><ul><li>With urine albumin/creatinine ratios more than 30mg albumin/1 gram creatinine </li></ul><ul><li>Without diabetes : </li></ul><ul><li>With urine albumin/creatinine ratios more than 300mg albumin/1 gram creatinine corresponding to about 1+ on standard dipstick </li></ul><ul><li>Or </li></ul><ul><li>Any patient: </li></ul><ul><li>With estimated GFR less than 60 mL/min/1.73 m 2 </li></ul>Jan 23 2009 12:30 PM Collaborative Care of CKD
  153. 153. How to Treat for Chronic Kidney Disease <ul><li>Maintain blood pressure less than 130/80 mmHg </li></ul><ul><li>Use an ACE Inhibitor or ARB </li></ul><ul><li>More than one drug is usually required and a diuretic should be part of the regimen </li></ul><ul><li>Continue best possible glycemic control in individuals with diabetes </li></ul><ul><li>Treat complications of CKD </li></ul>Jan 23 2009 12:30 PM Collaborative Care of CKD
  154. 154. Jan 23 2009 12:30 PM Collaborative Care of CKD Questions? NKF: www.kidney.org NKF-Va: www.kidneyva.org NKDEP www.nkdep.nih.gov

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