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Educational Objectives
Define chronic kidney disease (CKD)
Identify risk factors for progression and comorbid conditions
Discuss how early intervention improves
outcomes during CKD progression
Review measurements of kidney disease
Albuminuria:
eGFR:
<30
30+
90+
<30
30+
60-89
<30
30+ Sex: F
30-59
M
30-59
*Proportion of patients who were told they had weak or failing kidneys, eGFR (mL/min/1.73 m 2).
Coresh et al. J Am Soc Nephrol. 2005:16:180-188.
2005 The Johns Hopkins University School of Medicine.
Definition of
Chronic Kidney Disease
Stages of
Chronic Kidney Disease
Gend
er
Race
eGFR
(mg/dL)
(mL/min/1.73
m2 )
CKD
Stage
SCr
20
B*
1.3
91
20
1.3
75
55
1.3
61
20
1.3
56
55
1.3
55
50
1.3
46
Stages of CKD:
A Clinical Action Plan
Diabetes
The Leading Cause of Kidney
Failure
No Events
ESRD, CKD Stage 5
Death
Patients (%)
80
60
61.6
67.6
84.0
40
6.1
2.9
20
0
15.7
+ DM,
- CKD
0.3
29.5
32.3
- DM,
+CKD
+ DM,
+ CKD
Medical Cohort
CKD identified as ICD-9-CM diagnosis code, includes CKD from diabetes, hypertension,
obstructive uropathy, and other diagnosis codes reported on USRDS ESRD registration forms.
DM = diabetes mellitus; ESRD = end-stage renal disease; ICD-9-CM = International Statistical
Classification of Diseases, 9th Revision, Clinical Modification.
Collins et al. Kidney Int. 2003;64(suppl 87):S24-S31.
Intensive
Conventional
(n = 676)
(n = 673)
Creatinine
>2 mg/dL
5* (0.7%)
19 (2.8%)
Dialysis or
Transplant
4 (0.6%)
7 (1.0%)
Outcome
1.0
P<0.001
0.9
Incidence (%)
0.8
0.7
0.6
Overall: P<0.001
0.5
30
20
10
0
0
0
20
40
60
Follow-Up (mo)
80
100
Stroke
CHD
Events
Complication
Retinopathy
Nephropathy
Neuropathy
DCCT
A1C: (9
7%)
N = 1441
Kumamot
o
(9 7%)
N = 110
UKPDS
(8 7%)
N = 5102
76%
69%
17-21%
70%
24-33%
54%
60%
Hypertension
The Second Leading cause of
Kidney Failure
Goal BP
(mm Hg)
First Line
Adjunctive
+ Diabetes
<130/80
Diabetes
+ Proteinuria
<130/80
Diabetes
Proteinuria
<130/80
No specific preference:
Diuretics then ACE-I, ARB, CCB, or BB
RENAAL (N=1513)
-16
-22
-38
Ramipril vs
Metoprolol
P = 0.04
Losartan vs
Placebo
P = 0.02
IDNT (N=1722)
-20
Irbesartan
-23
vs Placebo Irbesartan
P = 0.02 vs Amlodipine
P = 0.006
Ramipril vs
Amlodipine
P = 0.004
P = 0.02
r = 0.69
P<0.05
Untreated
Hypertension
130/80
140/90
Anemia
A Modifiable and Funded Risk
Factor
NHANES III
NHANES 1999-2000
CKD Stage
*NHANES participants aged 20 y with anemia as defined by WHO criteria: hemoglobin (Hgb)
<12 g/dL for women, and Hgb <13 g/dL for men.
USRDS 2004 Annual Data Report. The data reported here have been supplied by the USRDS. The interpretation and
reporting of these data are the responsibility of the author(s) and in no way should be seen as an official policy or
interpretation of the U.S. government. Available at: www.usrds.org. Accessed 3/28/05.
2005 The Johns Hopkins University School of Medicine.
Parameter
Before
After
10.3
13.1
2.4
2.3
-0.95
0.27
3.8
2.7
8.9
2.7
Hospitalizations
3.7
0.2
132
131
75
76
Hgb (g/dL)
Serum creatinine (g/dL)
GFR (mL/min/mo)
Secondary
Hyperparathyroidism
An Early and Modifiable
Complication of CKD
Stage 2
5.7 million
Stage 3
7.4 million
Stage 4
300,000
40
30
25
20
300
Low-Normal
Calcitriol
200
10
0
400
iPTH (pg/mL)
Calcitriol
1,25(OH)2D3 (pg/mL)
50
100
High-Normal 65
PTH
105
95
85
75
65
55
45
35
25
15
PTH
PTH
Ca++
Bone Disease
Fractures
Serum P
Bone pain
Marrow fibrosis
Erythropoietin resistance
1,25D
Calcitriol
Systemic Toxicity
CVD
Hypertension
Inflammation
Calcification
Immunological
25D
Renal Failure
Ca = calcium; CVD = cardiovascular disease; P = phosphorus.
Courtesy of Kevin Martin, MB, BCh.
*
*
*
Observed/Expected
Incidence of Hip Fracture*
87
Overall
Male Relative Risk = 4.4
Female Relative Risk = 4.4
99
80
25 20
20
15
10 10
10
7.5
6.4
2.4 2.5
4.4 4.4
0
<45
45-54
55-64
65-74
Age (y)
75-84
Total
*Ratio of observed incidence of hip fracture in patients with kidney failure to expected incidence
of hip fracture in the general population.
Adapted from Alem et al. Kidney Int. 2000;58:396-399.
P<0.001
75
60-74
45-59
<45
Guideline 4.
Estimation of GFR
Guideline 4.
Estimation of GFR (contd)
Guideline 4.
Estimation of GFR (contd)
Serum Creatinine
Corresponding to GFR of
60 mL/min/1.73 m2
Clearance
and Serum Creatinine with
GFR (Inulin Clearance) in
Patients with Glomerular Disease
Prevalence of Individuals at
Increased Risk for CKD
Albuminuria:
eGFR:
<30
30+
90+
<30
30+
60-89
<30
30+ Sex: F
30-59
M
30-59
*Proportion of patients who were told they had weak or failing kidneys, eGFR (mL/min/1.73 m 2).
Coresh et al. J Am Soc Nephrol. 2005:16:180-188.
Summary
Over 20 millions Americans have some
degree of CKD & few are aware of it.
There are interventions to slow the
progression and treat the complications
that are associated with CKD.
Reporting eGFR can help alert health care
providers that their patient may have CKD
so further workup, education and
interventions can be done.