Chronic Kidney Disease (CKD)

1. Chronic Kidney Disease (CKD) Dr. Sham Sunder

2. Now we know why the titanic sank !! < 0.5 % 5- 10%

3. CKD – A scary Challenge for Us all !! CKD – Chronic kidney disease

4. We have intricate things to learn !!

5. Practice Guidelines of CKD The National Kidney Foundation (NKF) National Kidney Diseases Education Program The NKDEP KIDNEY / DISEASE OUTCOMES QUALITY INITIATIVEThe K/DOQI

6. Physicians Must be EngagedIndian scenario 80 lak pts with eGFR 30-60 ml/min/1.73 m2 Pts with albuminuria are double this number About 2,000 full-time nephrologists Nearly 4,000 new patients per nephrologist Means 11 new pts per day per nephrologist Obviously not possible. Physicians must treat CKD

7. CKD – A Silent Killer CKD – Increased Death CKD at a glance CKD – A Global Pandemic CKD 1-2 are asymptomatic Third after CVD, Cancer 1 in 10 Indians have CKD 10 million people of CKD Term ‘CRF’ no longer used Dialysis ↑ death rate 100 x Small ↑ in Creat - ↑ ↑ in CV

8. The Nephron

9. Filtration, Reabsorption and Secretion In a day 210 L of water is filtered Normal GFR 120 ml/min/1.73m2 Only 20% nephrons work at a time 2 L /day of urine is excreted

10. Definition of CKD • Either GFR < 60 ml/min/1.73m2 for  3 mon or • Kidney damage for  3 mon as manifested by • Persistent microalbuminuria / macroproteinuria • Biochemical abnormalities in RFT • Persistent non-urological hematuria • Structural renal abnormalities by USG • Biopsy proven Glomerulonephritis (rarely needed) (Any one of the above evidences)

11. CKD Clinical Stages

12. ESRD versus Total CKD

13. K/DOQI CKD Staging

14. Natural History of Nephropathy

15. Definition of ESRD vs Kidney Failure ESRD is a federal government defined term that indicates chronic treatment by dialysis or transplantation Kidney Failure: GFR < 15 ml/min/1.73 m2 or on dialysis

16. Global profile of ESRD

17. Prevalence of Abnormalities at each level of GFR *>140/90 or antihypertensive medication p-trend < 0.001 for each abnormality

18. CKD Features – Stage wise

19. Death rates from all causes (panel A) and cardiovascular events (panel B), as per eGFR Go, A, et al. NEJM 351: 1296

20. Physicians and Nephrologist in CKD

21. How to handle CKD ? A A1c < 6.5, ACEi, ARBs B Blood pressure < 125/75 C Cholesterol LDL < 100 D Drugs – avoid nephrotoxicity Diet – Moderate in protein Na, K, Ph, Fluids, Cal

22. CKD – Management Strategy • Decrease Cardiovascular Risk • Arrest or slow progression to ESRD • Manage complications – • Anemia (Normocytic normochromic) • Bone loss (Renal osteodystrophy)

23. CKD – Management Goals • Blood pressure < 125/75 • HT is both a cause and consequence • Glycemic control – Hb A1c < 6.5 • Hemoglobin level > 11 g% • Calcium x Phosphorous product < 50 Normal values : GFR 120 to 150 ml/min/1.73m2 Ca 9 to10.5mg%, Ph 3 to 4.5mg%, Ca x Ph < 50 iPTH 150 to 300 pg/ml

24. Early treatment makes a difference in CKD Brenner, et al., 2001

25. Stages in Progression of Chronic Kidney Disease and Therapeutic Strategies Complications Normal Increasedrisk Damage  GFR Kidneyfailure CKDdeath Screening for CKDrisk factors CKD riskreduction;Screening forCKD Diagnosis& treatment;Rx. comorbidconditions;↓ progression Estimateprogression; Rx. complications;Prepare forreplacement Replacementby dialysis& transplant

26. Stage-wise management of CKD

28. Preparation for RRT • Choice of Renal Replacement • Timely Access Surgery • Timely Dialysis initiation • When GFR < 25ml/min • Renal transplant is the first choice • Workup living donors • If no donors available • List patient on cadavre transplant list • Place A-V fistula if HD preferred

29. Conclusions • CKD – ESRD patient population is increasing in our country • Early detection and proper management has many advantages • Later stages, i.e. ESRD – RRT is required • Various modalities of RRT – Dialysis (Hemo/ Peritoneal) as well as renal transplantation available

30. Let this not happen please! Normal ESRD

31. Thank You!