Boston Kidney Health Series 2013 Kidney Disease 101:

Function, Causes, and Treatment

Albert Q. Lam, MD Associate Physician

Division of Renal (Kidney) Medicine

Brigham and Women’s Hospital

Disclosures

• None to report

Introduction

• Kidney anatomy and function

• Chronic kidney disease – a public health

problem

• Kidney disease recognition and diagnosis

• Kidney disease treatment and prevention

Kidneys 101: Anatomy

www.webmd.com

Kidneys 101: Anatomy

The basic unit of the kidney is a NEPHRON.

www.unckidneycenter.org

Kidneys 101: Anatomy

+

A nephron … simplified.

=

How do your kidneys work?

• Eliminate waste products from the body

• Eliminate drugs from the body

• Maintain body fluid, electrolyte, and acid

balance

• Produce hormones that:

– Regulate blood pressure

– Promote bone health

– Produce red blood cells

Types of Kidney Disease

• Acute kidney injury (AKI)

– Sudden loss of kidney function occurring over hours to days

– Can be reversible

• Chronic kidney disease (CKD)

– Kidney damage or loss of kidney function lasting three months or longer

• End stage renal disease (ESRD)

– Total and permanent kidney failure

– Dialysis or transplant required for survival

What is chronic kidney disease

(CKD)?

• Any condition that damages the kidneys

and prevents them from keeping the body

healthy (present for 3 months or longer)

• Kidneys lose the ability to get rid of waste

products and regulate body fluid

• Associated with complications such as

high blood pressure, anemia, bone

disease, and poor nutrition

CKD: a major public health problem

• 26 million Americans are affected by

kidney disease

– As of 2012, 14% of Americans have CKD

– Affects more than 35% of adults with diabetes

– Affects more than 20% of adults with

hypertension

• CKD costs Medicare $41 billion per year

– 17% of Medicare expenditures

CKD is associated with cardiovascular

disease

USRDS 2013

CKD patients have higher hospitalization

and death rates

USRDS 2012

ESRD patients have higher death rates

USRDS 2013

Less than 1/3rd of CKD patients see a

kidney doctor

USRDS 2013

16

20 13USRDSannua ldat ar epor t

volume oneck d

0 100 200 300 400 500

Stage 1-2

Stage 3

Stage 4-5576

416

361Hospitaliza tions per1,000 patient years

0 20 40 60 80 100

.

109

64

65Stage 1-2

Stage 3

Stage 4-5

Deaths per 1,000patien t years

Medicare patien ts age and older are twice as likely t o see a cardiologist as a nephrologist following

any diagnosis for CKD. Among pa tien ts with a CKD diag nosis of Stage or higher, approximately two-

thirds see either a cardiologist or nephrologist in the year following the diag nosis.

Patients who see a primary

care physician

Patien ts

who see a

cardiolog ist

Patien ts

who see a nephrolog ist

All CKD CKD code of 585.3 or hIgher

Hospitalization rates

All-cause rehospitalization Rehospitalization after all-cause index hospitalization

Rehospitalization after cardiovascular index hospitalization

Mortality rates

No CKD

Generalpopulation(no CKD)

Generalpopulation(no CKD)

Generalpopulation(no CKD)

No CKDAll CKD

All CKD All CKD All CKDHemodialysis . – . –. .. – . –

All CKD

38% HIGHER 37% HIGHER

adjusted all-cause HOSPITALIZATION AND MORTALITY RATESare HIGHER IN CKD PATIENTS than in those without the disease

adjusted rates of REHOSPITALIZATION are also

HIGHER IN CKD PATIENTS than in those without the disease

. . .. . .. .. . .. .

Physician care: Tables .g–hAcute kidney injury: Figures . –

Hospitaliza tion: Table .a

Mortalit y: Table .cRehospitaliza tion: Figures . & . –

Acute kidney injury is highly associated with age, & rates of f rst AKI (per 1,000 patient years at risk) have increased

Patients rehospitalized within 30 days of a live hospital discharge (age 66 & older)

Truven Health ClInformatIcs MedIcare MarketScan DataMart 2001 2011 2001 2011 2001 2011

20-44 0.15 0.65 0.14 0.6545-54 0.47 1.82 0.45 1.8154-64 1.06 4.31 1.09 4.366-69 3.7 14.970-74 4.9 18.875-79 6.6 26.480-84 8.0 35.985+ 9.6 49.6

WhIte 5.7 25.8Black/Af Am 11.9 45.3

ch onic i ne iseIN THE UNITED STATES

How does my doctor know if I

have CKD? • Blood test for creatinine

– A waste product from muscle breakdown

– Normal: 0.7-1.2 mg/dL

– Depends on muscle mass

• Determine your glomerular filtration rate (GFR) – A measure of your kidney function

– Normal: 90-120 mL/min

• Urine test for protein – A sign of kidney damage, if persistent

– Normal: <150 mg/day

Stages of CKD

Stage Description GFR

1 Kidney damage with

normal GFR 90 or above

2 Kidney damage with mild

decrease in GFR 60-89

3 Moderate decrease in

GFR 30-59

4 Severe reduction in GFR 15-29

5 Kidney failure Less than 15

What causes CKD?

• Diabetes

• High blood pressure • Other conditions

– Glomerulonephritis

– Inherited diseases

– Congenital (birth) defects

– Autoimmune disease (lupus)

– Urinary obstruction

– Repeated urinary tract infections

What are the symptoms of

CKD?

Most patients have no symptoms until kidney

disease is advanced.

http://www.lightersideofdialysis.com

What are the symptoms of

CKD?

• Fatigue and decreased energy

• Trouble concentrating

• Poor appetite

• Nausea/vomiting

• Swollen feet and ankles

• Itchiness

• Trouble sleeping

What will happen if I have CKD?

• Progression of CKD can

lead to kidney failure and the

need for dialysis or a

kidney transplant

• Early detection and

treatment are important to

prevent kidneys from getting

worse

Treatments for kidney failure (ESRD)

http://trialx.com

http://www.lincolndocs.com

http://www.ninephrology.com/home_dialysis.htm

http://blogs.itb.ac.id/pahlev/2012/03/29/peritoneal-dialysis/l

IN-CENTER

HEMODIALYSIS

HOME

HEMODIALYSIS

PERITONEAL

DIALYSIS

Can CKD be treated?

• Many kidney diseases can be treated

successfully

– Diabetes

– High blood pressure

– Glomerular diseases (immunosuppressants)

• Some causes of kidney disease are

unknown and do not have specific

treatments

– More research is needed

8 steps to prevent and treat

kidney disease

Step #1:

Visit your physician regularly

8 steps to prevent and treat

kidney disease

Step #2:

Take control of your blood pressure

Take control of your blood pressure

• Measure your BP at home regularly

• Your BP goal:

– < 140/90 if your doctor says you have no protein in your urine

– < 130/80 if your doctor says you have protein in your urine

• You may benefit from taking an ACE inhibitor or angiotensin receptor blocker

8 steps to prevent and treat

kidney disease

Step #3:

If you diabetic, take control of your blood

sugar levels

Take control of your blood sugars

• Measure your blood glucose levels at home regularly

• Work with a dietitian or your doctor to create healthy diets that you can follow

• Take your diabetic medications as prescribed

• Alert your doctor if you notice your levels are frequently too high or too low

8 steps to prevent and treat

kidney disease

Step #4:

Eat a healthy diet.

*Low salt

*Heart healthy

8 steps to prevent and treat

kidney disease

Step #5:

Take control of your weight.

8 steps to prevent and treat

kidney disease

Step #6:

Stop smoking.

8 steps to prevent and treat

kidney disease

Step #7:

Take medications appropriately.

Take medications appropriately

• Make sure your doctor has dosed your medications appropriately for your level of kidney function

• Avoid medications and other agents that are potentially toxic to your kidneys – Non-steroidal anti-

inflammatory drugs (NSAIDS) (e.g. ibuprofen)

– Intravenous contrast dye (CT scans, angiograms)

– Herbal remedies (e.g. aristolochic acid)

8 steps to prevent and treat

kidney disease

Step #8:

Get educated. Get prepared. Get active.

Get educated. Get prepared.

Get active.

• Learn about your kidneys

• Understand your disease

• Take an active partnership role in the care of your kidneys – Engage your doctor (ask questions, get clear answers)

– Know and understand your treatment plan (e.g. medications, follow-up tests)

– Recognize when things are not going well or when changes need to be made

• If your kidney disease is advanced, discuss the treatment options with your nephrologist early

• Early preparation is the key to a successful outcome

What your kidney doctor will do

• Try to determine the cause of your kidney disease and treat if reversible

• Manage the complications of CKD – Hypertension

– Proteinuria (protein in your urine)

– Anemia

– Cardiovascular disease

– Acidosis

– Bone disease

– Nutrition

• Educate you and prepare you for the need for dialysis or transplantation

Questions?