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Chronic Kidney Disease The Recognized Epidemic

Chronic Kidney Disease The Recognized Epidemic. Shagun Chopra m.D. Director of dialysis &Transplant NMcsd Assistant professor of medicine ucsd Assistant professor of medicine usuhs. Outline. ESRD What is CKD? Epidemiology of CKD? What does CKD predict?

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Chronic Kidney Disease The Recognized Epidemic

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  1. Chronic Kidney DiseaseThe Recognized Epidemic Shagun Chopra m.D. Director of dialysis &Transplant NMcsd Assistant professor of medicine ucsd Assistant professor of medicine usuhs

  2. Outline • ESRD • What is CKD? • Epidemiology of CKD? • What does CKD predict? • What can I do for my CKD patient? • Where are we going with CKD?

  3. The number of individuals initiating treatment for end-stage renal disease (ESRD) in the United States, according to cause and calendar year, 1980 to 1999 (RenDER system of the United States Renal Data System (USRDS) (http://www.usrds.org)..

  4. ESRD prevalence counts and prevalence rates in the U.S. Graphic from USRDS 2010 Annual Report

  5. Medicare expenditures on ESRD, not adjusted for inflation. Graphic from USRDS 2010 Annual Report

  6. ESRD • Why is the life expectancy so poor? • Why doesn’t a drug change survival in the dialysis patient? • Why is the CV risk so high? • Is it too late? • When should we start?

  7. Measurement of GFR • Inulin clearance- Gold standard • Cockroft-Gault: 1976. Measures CrClr. Studied in 249 indiv. No AA. Overestimates due to secretion as well in edematous, hypoalbuminemic and nephrotic states • MDRD-1999. 1628 CKD patients. 6% DM. Underest if >60. Overestimates in malnourished, vegetarian diet and nephrotic states. • Cystatin C. made by nucleated cells. Altered by inflammatory states, leukocytosis, age, gender, diabetes etc. Not FDA approved.

  8. CKD Is Common: ~ 27 Million Americans Have CKD *Prevalent dialysis patients. 1. US Renal Data System. USRDS 2007 Annual Data Report: Atlas of Chronic Kidney Disease and End-Stage Renal Disease in the United States. 2007; 2. Coresh J, et al. JAMA. 2007;298:2038-2047; 3. Available at: http://www.kidney.org/news/newsroom/newsprint.cfm?id=51. Accessed April 18, 2008.

  9. CKD & CVD DM, HTN Anemia Coronary Calcification Cax Po4 <55 Worsening HTN Nephrotic syndrome Hyperlipidemia

  10. Management of CKD Etiology of CKD/Progression Anemia Access Adequacy BP Bone Mineral disorder Cardiovascular Risk Diet/Nutrition Medication Reconciliation

  11. Etiology/Progression • In the MDRD study Rate of Progression of CKD varies based on : • Underlying disease, proteinuria, Stage of CKD, comorbidities and treatments. • Retrospective analysis of MRFIT data showed that :1+proteinuria-3.1%, 2+ 15.7%, GFR 60-30 2.4%, GFR <30 41% over a 10 year period.

  12. Management of CKD Etiology of CKD/Progression Anemia Access Adequacy BP Bone Mineral disorder Cardiovascular Risk Diet/Nutrition Medication Reconciliation

  13. TREAT

  14. Management of CKD Etiology of CKD/Progression Anemia Access Adequacy BP Bone Mineral disorder Cardiovascular Risk Diet/Nutrition Medication Reconciliation

  15. Access • GFR <25ml/min or rapid progression consider placement of hemodialysis access. • Transplant referral at GFR<30 and placement on transplant list at <20. • AVF • AVG • Tunneled Catheter • Periotenal dialysis

  16. Adequacy • Is the GFR adequate to avoid: volume overload, uremic sxs- nausea, malnutrition, pericarditis, lethargy, hyperk, acidosis. Most common reasons to start- malnutrition and volume overload. • ?GFR<15ml/min per NKF are indications to consider the risks and benefits to initiating dialysis. • European Best Practice guidelines state GFR<6ml/min and consider at 8-10

  17. Management of CKD Etiology of CKD/Progression Anemia Access Adequacy BP Bone Mineral disorder Cardiovascular Risk Diet/Nutrition Medication Reconciliation

  18. Safety • NEJM 2006, Efficacy and Safety of Benazepril for advanced renal insuff • Benazepril vs placebo and both groups had BP<130/80. Both groups had 1.5gm proteinuria and GFR 25ml/min. • Benazepril reduced protenuria and lowered progression to ESRD and adverse events (hyperk) same.

  19. BP • MDRD trial subgroup evaluated aggressive BP lowering <125/75 vs <130/80: in 585 patients mean GFR<40ml/min • Decline in GFR was lowest in <1gm proteinuria but no benefit in aggressive BP arm • Patients with 1-3gm proteinuria had more rapid progression and a modest benefit from a lower BP • >3gm had the fastest rate of progression but a substantial benefit- 10.2 to 6.5ml/min per year. • Similar trends in another group with GRF<19ml/min

  20. Management of CKD Etiology of CKD/Progression Anemia Access Adequacy BP Bone Mineral disorder Cardiovascular Risk Diet/Nutrition Medication Reconciliation

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