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Heart and Kidney: Protect Your Kidneys to Save Your Heart

Heart and Kidney: Protect Your Kidneys to Save Your Heart . Dr Rajendra Prasad Mathur MD, DM, FICP, ISN Scholar Seniour consultant & HOD, Batra hospital. Overview. CKD – Global and Indian scenario World Kidney Day CVD and Kidney Proteinuria and CVD

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Heart and Kidney: Protect Your Kidneys to Save Your Heart

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  1. Heart and Kidney: Protect Your Kidneys toSave Your Heart Dr Rajendra Prasad Mathur MD, DM, FICP, ISN Scholar Seniour consultant & HOD, Batra hospital

  2. Overview • CKD – Global and Indian scenario • World Kidney Day • CVD and Kidney • Proteinuria and CVD • Treatment of CKD reduce CVD risk • Conclusions

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

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

  5. 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

  6. ESRD versus Total CKD ESRD - end-stage renal disease

  7. Global profile of ESRD

  8. India: Kidney disease burden • India is the world’s largest democracy with a population of around 1.13 billion and faces tremendous challenges to provide basic healthcare for its masses • The incidence rates of ESRD in India • 232 per million population (age adjusted rate) NDT Plus 2010; 3: 203–207

  9. India: Kidney disease burden • The Indian CKD registry is an initiative by the Indian Society of Nephrology, and out of the latest total of 35 697 CKD patients, • 26 609 (74.5%) amongst the CKD patients were not receiving any form of RRT (renal replacement therapy) and • only 880 (2.5%) received renal transplantation (RT) • It is estimated that • >90% of patients with ESRD in South Asia die within months of diagnosis because they cannot afford treatment NDT Plus 2010; 3: 203–207

  10. World Kidney Day • World Kidney Day (WKD) • Annual event jointly sponsored by the • International Society of Nephrology and the International Federation of Kidney Foundations, • Inception in 2006 • Being celebrated 2nd Thursday every March Nephrol Dial Transplant 2011;26: 395–398

  11. World Kidney Day • World Kidney Day (WKD) • Grown dramatically to become • The most widely celebrated event associated with kidney disease in the world and • The most successful effort to raise awareness among both the general public and government health officials about the dangers of kidney disease, especially chronic kidney disease (CKD) Nephrol Dial Transplant 2011;26: 395–398

  12. World Kidney Day 2011 Theme • World Kidney Day (WKD) • This year on 10th March, 2011 • WKD was celebrated with theme • Protect Your Kidneys, Save Your Heart Nephrol Dial Transplant 2011;26: 395–398

  13. Kidney disease is common, harmful and treatable

  14. Cardiovascular disease (CVD) and the kidney • CVD • The most common of the chronic non-communicable diseases (NCDs) that impact global mortality • About 30% of all deaths worldwide and • 10% of all healthy life lost to disease are accounted for by CVD alone Nephrol Dial Transplant 2011;26: 395–398

  15. CVD and kidney • The presence of CKD significantly increases the risk of a CV event in both diabetes and hypertension • However, less well appreciated is that CKD alone is a strong risk factor for CVD, independent of diabetes, hypertension or any other conventional CVD risk factors • This is especially true when an increase in proteinuria, a major target of any CKD screening programme, is present Nephrol Dial Transplant 2011;26: 395–398

  16. CVD and kidney • The 20–30-fold increase in CVD in patients with ESRD has long been recognized, but • The increased risk for CVD associated with lesser degrees of renal functional impairment was definitively demonstrated only in 2004 • Study by Go et al, published in NEJM Nephrol Dial Transplant 2011;26: 395–398

  17. CVD and kidney • Go et al • Study Methods: • Estimated the longitudinal GFR among 1,120,295 adults within a large, integrated system of health care delivery in whom • Serum creatinine had been measured between 1996 and 2000 and who had not undergone dialysis or kidney transplantation • Examined the multivariable association between the • Estimated GFR and the risks of death, cardiovascular events, and hospitalization N Engl J Med 2004;351:1296-305.

  18. CVD and kidney • Go et al • Results N Engl J Med 2004;351:1296-305.

  19. CVD and kidney • Go et al • Results N Engl J Med 2004;351:1296-305.

  20. CVD and kidney • Go et al • Results N Engl J Med 2004;351:1296-305.

  21. CVD and kidney • Go et al • Conclusions • An independent, graded association was observed between a reduced estimated GFR and the risk of death, cardiovascular events, and hospitalization in a large, community based population • These findings highlight the clinical and public health importance of chronic renal insufficiency N Engl J Med 2004;351:1296-305.

  22. CVD and kidney • Is this dramatic increase in CVD risk associated with CKD really due to CKD or does it just reflect the coexistent diabetes or hypertension that is present in a majority of these patients? • The independent effect of CKD alone has now been well documented in many studies J Am Soc Nephrol 2006; 17: 2034–2047

  23. CVD and kidney • The risk of cardiac death is increased (46%) in people with a GFR between 30 and 60 mL/min (stage 3 CKD) • Independent of traditional CV risk factors including diabetes and hypertension J Am Soc Nephrol 2008; 19: 158–163

  24. J Am Soc Nephrol 2008; 19: 158–163

  25. J Am Soc Nephrol 2008; 19: 158–163

  26. CVD and kidney • The increased risk for CV events and mortality in people >55 years with CKD alone is equivalent, or even higher, to that seen in patients with diabetes or previous myocardial infarcts Am J Cardiol 2008; 102: 1668–1673

  27. CVD and kidney • Both general * and high-risk populations ** exhibit an increased risk of CVD with CKD • This increased risk for CVD is not confined to the elderly—in volunteers with an average age of 45, • The risk for myocardial infarct, stroke and all-cause mortality was doubled in those with CKD • *N Engl J Med 2004; 351: 1296–1305, Am J Kidney Dis 2008; 51: S38–S45 • **Arch Intern Med 2007; 167: 1122–1129 • Am Heart J 2008; 156:277–283

  28. Kidney dysfunction increases the risk of cardiovascular disease significantly

  29. Proteinuria and CV risk • In considering the value of recommending screening for CKD along with conventional CVD risk factors in selected individuals, the data showing that • The risk of CVD is better correlated with proteinuria (albuminuria) than with GFR alone are particularly relevant because • Proteinuria is virtually always a marker of kidney disease and is not a conventional CVD risk factor Nephrol Dial Transplant 2011;26: 395–398

  30. Proteinuria and CV risk • With regard to proteinuria as a predictor of later CVD, • The PREVEND study showed • A direct linear relationship population even at levels of albumin excretion generally considered within the ‘normal’ range (15–29 mg/day) and • was increased >6-fold when albumin excretion exceeded 300 mg/day Circulation 2002; 106: 1777–1782

  31. Proteinuria and CV risk • Recent data from the US NHANES database as well as from Japan also document • An independent effect of albuminuria on risk of both CVD and all-cause mortality at all levels of GFR • In patients with congestive heart failure but without diabetes, hypertension or reduced GFR, • Increased urinary albumin predicts both CV and all cause mortality Nephrol Dial Transplant 2011;26: 395–398

  32. Proteinuria and CV risk • Similar results are obtained studying patients with coronary disease or previous myocardial infarcts in whom • Proteinuria conferred a greater risk of mortality than reduced GFR, • Although both adversely impacted outcomes BMJ 2006; 332: 1426

  33. Proteinuria and CV risk • Of interest, not only the likelihood but also the time to development of a CV event is accelerated significantly by the presence of proteinuria at all levels of GFR Nephrol Dial Transplant 2011;26: 395–398

  34. Proteinuria and CV risk • In non-diabetic subjects with normal serum creatinine levels undergoing percutaneous coronary interventions, • ~78% have demonstrable CKD when screened more stringently for renal function (eGFR and urine protein) • Not only is the presence of CKD a likely factor in accelerating development of coronary disease in these patients but it has also been associated with • An increase in other risks including haemorrhagic complications, contrast nephropathy, re-stenosis and death Nephrol Dial Transplant 2011;26: 395–398

  35. Proteinuria and CV risk • Thus, multiple studies now confirm that • Proteinuria is a graded risk factor for CVD independent of GFR, hypertension and diabetes, and • This risk extends down into ranges of albumin excretion generally considered ‘normal’ • This increased CV risk has been well demonstrated in several studies where only dipsticks were used to screen for increased protein excretion Nephrol Dial Transplant 2011;26: 395–398

  36. Get your blood pressure checked, blood and urine tests done for early detection of kidney dysfunction

  37. Can treatment of CKD reduce CVD? • Finally, and most importantly from a clinical perspective, • There are provocative data suggesting that • Renal-targeted interventions designed to reduce proteinuria and slow progression of CKD can reduce CVD risk as well Nephrol Dial Transplant 2011;26: 395–398

  38. Can treatment of CKD reduce CVD? • Angiotensinconverting enzyme inhibitors (ACEIs) and/or angiotensin receptor blockers (ARBs) are of documented benefit in slowing progression of established diabetic and non-diabetic CKD Lancet 1999; 354: 359–364 Lancet 1998; 352: 1252–1256 Lancet 1997; 349: 1857–1863 N Engl J Med 2009; 361: 1639–1650

  39. Can treatment of CKD reduce CVD? • Of interest related to slowing progression, • The incidence of CVD in CKD is significantly higher with more rapid loss of GFR independent of other risk factors, • Suggesting that interventions that slow progression may also reduce CVD JAm Soc Nephrol 2009; 20: 2617–2624

  40. Can treatment of CKD reduce CVD? • A 44% reduction in CV mortality over 4 years has been reported in patients screened from a general population with no risk factors except increased albumin in the urine and treated with renal-targeted ACEI therapy • This effect was seen primarily in people with albumin excretion rates of >50 mg/day in a pilot study, and the • Intervention was shown to be cost-effective in that population Circulation 2004; 110: 2809–2816 ClinTher 2006; 28: 432–444

  41. Can treatment of CKD reduce CVD? • CV end points were significantly reduced in direct proportion to the reduction of albuminuria with ACEI therapy, and • Albuminuria proved to be the only predictor of CV outcome • Other studies have also demonstrated that • Changes in proteinuria (in diabetics) better predict outcomes than changes in blood pressure (BP) achieved with ACEI therapy Nephrol Dial Transplant 2011;26: 395–398

  42. Can treatment of CKD reduce CVD? • The potential benefit of renal-targeted therapies has recently been highlighted by observations that • Higher doses of renin–angiotensin system (RAS) blockers than required for BP control alone can further reduce proteinuria independent of effects on BP or GFR, and • Addition of salt restriction or diuretics, both very inexpensive interventions, can further enhance the proteinuria-reducing effect of RAS blockade Nephrol Dial Transplant 2011;26: 395–398

  43. Can treatment of CKD reduce CVD? • Data are not yet available to establish that • Sscreening for CKD and subsequent interventions will reduce CV mortality and be cost-effective in younger people (<55 years) • It is now known that • Albuminuria is a better predictor of renal and cardiovascular events than blood pressure alone, • Reducing proteinuria is more renal and cardio-protective than lowering blood pressure alone and • Identification of CKD can improve CV outcomes Nephrol Dial Transplant 2011;26: 395–398

  44. Don’t treat Diabetes, to your kidneys. Untreated diabetes can lead to kidney diseases. Protect your kidney, control diabetes

  45. Physicians and Nephrologist in Management of CKD

  46. 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

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

  48. 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

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

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