Chronic Kidney Disease Definition
Transcript of Chronic Kidney Disease Definition
Chronic Kidney DiseaseDefinition, Early Intervention &
Measurement
Andrea Easom Ma, MNSc, APN, BC. CNN
University of Arkansas for Medical Sciences
Instructor, College of Medicine, Nephrology Division
Educational Objectives
• Define chronic kidney disease (CKD)
• Identify risk factors for progression and co-morbid conditions
• Discuss how early intervention improves outcomes during CKD progression
• Review measurements of kidney disease
1.1 1.62.4 2.9
3.95.5
17.918.6
0
5
10
15
20
Pat
ien
ts W
ho
Are
Aw
are
of
Wea
k o
r F
ailin
g K
idn
eys*
(%
)
Awareness of Early-Stage CKD Is Low in the US Population
*Proportion of patients who were told they had weak or failing kidneys, eGFR (mL/min/1.73 m2). Coresh et al. J Am Soc Nephrol. 2005:16:180-188.
<30 30+ <30 30+ <30 30+ F MSex: Albuminuria:
eGFR: 90+ 60-89 30-59 30-59
© 2005 The Johns Hopkins University School of Medicine.
Definition of Chronic Kidney Disease
AJKD 2002: 39(2)
Stages of Chronic Kidney Disease
AJKD 2002: 39(2)
Definition and Stages of Chronic Kidney Disease
AJKD 2002: 39(2)
Stages in Progression of CKD and Therapeutic Strategies
AJKD 2002: 39(2)
Risk Factors for Adverse Outcomes of CKD
AJKD 2002: 39(2)
Potential Risk Factors for Susceptibility to and
Initiation of CKD
AJKD 2002: 39(2)
AJKD 2002: 39(2)
Why Estimate GFR From SCr, Instead of Using SCr for Kidney Function?
*B = black; †W = all ethnic groups other than black. GFR calculator available at: www.kidney.org/index.cfm?index=professionals. Accessed 3/28/05.
AgeGend
er RaceSCr
(mg/dL)
eGFR (mL/min/1.73
m2)
CKD Stage
20 M B* 1.3 91 1
20 M W† 1.3 75 2
55 M W 1.3 61 2
20 F W 1.3 56 3
55 F B 1.3 55 3
50 F W 1.3 46 3
Stages of CKD: A Clinical Action Plan
AJKD 2002: 39(2)
Evaluation of Proteinuria in Patients
Not Known to Have Kidney Disease
AJKD 2002: 39(2)
Diabetes
The Leading Cause of Kidney Failure
Increased Mortality in Patients With Diabetes and CKD: 2-Year Clinical Outcomes
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.
+ DM, - CKD
- DM,+CKD
+ DM,+ CKD
Medical Cohort
Pat
ien
ts (
%)
0
20
40
60
80
100
84.067.6 61.6
No Events
29.515.7
32.3
DeathESRD, CKD Stage 5
0.3
2.96.1
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Advanced Kidney Outcomes by Year 8 of EDIC Reduced by Intensive Treatment
OutcomeIntensive
(n = 676)Conventional
(n = 673)
Creatinine >2 mg/dL
5* (0.7%) 19 (2.8%)
Dialysis or Transplant
4 (0.6%) 7 (1.0%)
EDIC = Epidemiology of Diabetes Interventions and Complications.*P = 0.004. Writing team for the DCCT/EDIC Research Group. JAMA. 2003;290:2159-2167.
© 2005 The Johns Hopkins University School of Medicine.
Proteinuria Predicts Stroke and CHD Events in Patients With Type 2
Diabetes
P<0.001
40
30
20
10
0Stroke CHD
Events80604020
0
0.5
0.6
0.7
0.8
0.9
1.0
Su
rviv
al C
urv
es f
or
CV
Mo
rtal
ity
Overall: P<0.001
Inci
den
ce (
%)
Follow-Up (mo)
CHD = coronary heart disease; Prot = urinary protein excretion; CV = cardiovascular.Miettinen et al. Stroke. 1996;27:2033-2039.
Prot 150-300 mg/LProt <150 mg/L Prot >300 mg/L
0 100
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Evidence for Effects of Good Glycemic Control on Complications, Including
Nephropathy
DCCT = The Diabetes Control and Complications Trial.DCCT Study Group. N Engl J Med. 1993;329:977-986; Ohkubo. Diabetes Res Clin Prac. 1995;28:103-117; UKPDS Study Group. Lancet. 1998;352:837-853.
Trial
Complication
DCCTA1C: (9
7%)N = 1441
Kumamoto
(9 7%)N = 110
UKPDS(8 7%)N = 5102
Retinopathy 76% 69% 17-21%
Nephropathy 54% 70% 24-33%
Neuropathy 60% – –
© 2005 The Johns Hopkins University School of Medicine.
Hypertension
The Second Leading cause of Kidney Failure
Recommendations for BP and RAS Management in CKD
BP = blood pressure; RAS = renin angiotensin system; CCB = calcium channel blocker; BB = -blocker; JNC 7 = The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure.ADA. Diabetes Care. 2005;28(suppl 1); Chobanian et al. JAMA. 2003;289:2560-2572; Kidney Disease Outcomes Quality Initiatives (K/DOQI). Am J Kidney Dis. 2004;43(5 suppl 1):S1-S290.
PatientGroup
Goal BP(mm Hg) First Line Adjunctive
+ Diabetes <130/80 ACE-I or ARB Diuretics then CCB or BB
Diabetes + Proteinuria
<130/80 ACE-I or ARB Diuretics then CCB or BB
Diabetes Proteinuria
<130/80 No specific preference:
Diuretics then ACE-I, ARB, CCB, or BB
EXPECT TO NEED TO USE 3+ AGENTS TO ACHIEVE GOALSRecommendations largely consistent across JNC 7, ADA, and K/DOQI
© 2005 The Johns Hopkins University School of Medicine.
ACEI/ARB & Reduced Risk of Rapid GFR Decline, Kidney Failure, or Death
-50
-40
-30
-20
-10
0
Co
mp
osi
te R
isk
(%)*
Wright et al for the AASK Study Group. JAMA. 2002;288:2421-2431. [AASK - African American Study of Kidney Disease and Hypertension]Brenner et al for the RENAAL Study Investigators. N Engl J Med. 2001;345:861-869. [RENAAL = Reduction of Endpoints in NIDDM with the Angiotensin II Antagonist Losartan]Lewis et al for the Collaborative Study Group. N Engl J Med. 2001;345:851-860.[IDNT = Irbesartan in Diabetic Nephropathy Trial.]
Ramipril vs Amlodipine
P = 0.004
Ramipril vs Metoprolol
P = 0.04
Losartan vs Placebo P = 0.02
-38
-22
-16
Irbesartan vs Placebo
P = 0.02
-20
Irbesartan vs Amlodipine
P = 0.006
-23
AASK (N=1094) RENAAL (N=1513) IDNT (N=1722)
© 2005 The Johns Hopkins University School of Medicine.
0
5
10
15
20
25
30
0 6 12 18 24 30 36
Follow-Up (mo)
Pat
ien
ts R
each
ing
En
d P
oin
t* (
%)
*Primary end point: doubling of SCr or kidney failure.Nakao et al. Lancet. 2003;361:117-124.
ACEIs, ARBs, and Combination Therapy Effects in Nondiabetic Nephropathy
P = 0.02
Combination (n = 88)Losartan (n = 89)Trandolapril (n = 86)
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Relationship Between Achieved BP and GFR
-14
-12
-10
-8
-6
-4
-2
0
95 98 101 104 107 110 113 116 119
eG
FR
(m
L/m
in/1
.73 m2)
per
y
MAP = Mean Arterial Pressure*
r = 0.69P<0.05
UntreatedHypertension
130/80 140/90
*MAP = [SBP + (2 × DBP)]/3 mm Hg.Summary of 9 studies used in figure.Parving et al. 1989; Viberti et al. 1993; Klahr et al. 1993; Hebert et al. 1994; Lebovitz et al. 1994; Moschio et al. 1996; Bakris et al. 1996; Bakris et al. 1997; GISEN Group. 1997.Bakris et al. Am J Kidney Dis. 2000;36:646-661.
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Anemia
A Modifiable and Funded Risk Factor
*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.
Anemia Prevalence by CKD Stage
Pat
ien
ts W
ith
An
emia
* (%
)
0
10
20
30
40
50
60
70
1 2 3 4-5
NHANES IIINHANES 1999-2000
CKD Stage
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Anemia Treatment Eligibility
• Serum Creatinine (2.0 mg/dl or above) or
• Creatinine Clearance (45 ml/min or below) and
• Hemoglobin (11g/dl or below) or
• Hematocrit (33% or below) or
• Symptoms of anemia
Consequences of Anemia in CKD• Reduced oxygen delivery to tissues• Decrease in Hgb compensated by increased cardiac
output• Progressive cardiac damage and progressive renal
damage1
• Increased mortality risk2
• Reduced quality of life (QOL)3
– Fatigue– Diminished exercise capacity– Reduced cognitive function
• Left ventricular hypertrophy (LVH)4
1. Silverberg et al. Blood Purif. 2003;21:124-130. 2. Collins et al. Semin Nephrol. 2000;20:345-349; 3. The US Recombinant Human Erythropoietin Study Group. Am J Kidney Dis. 1991;18:50-59; 4. Levin. Semin Dial. 2003;16:101-105.
© 2005 The Johns Hopkins University School of Medicine.
Patients With CHF and Anemia (n = 126, 91% CKD)
NYHA class = New York Heart Association classification; SOB = shortness of breath.Silverberg et al. Perit Dial Int. 2001;21(suppl 3):S236-S240.
Clinical Benefit of Anemia Correction: CHF and CKD
Parameter Before AfterHgb (g/dL) 10.3 13.1
Serum creatinine (g/dL) 2.4 2.3
∆GFR (mL/min/mo) -0.95 0.27
NYHA class (0-4) 3.8 2.7Fatigue/SOB index (0-10) 8.9 2.7
Hospitalizations 3.7 0.2
Systolic BP (mm Hg) 132 131
Diastolic BP (mm Hg) 75 76
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Secondary Hyperparathyroidism
An Early and Modifiable Complication of CKD
Calcitriol Decline and iPTH Elevation as CKD Progresses
N = 150.iPTH = intact PTH. Adapted from Martinez et al. Nephrol Dial Transplant. 1996;11(suppl 3):22-28.
eGFR (mL/min/1.73 m2)
152535455565758595105
100
200
300
400
0
10
20
30
40
50
iPT
H (
pg
/mL
)
Cal
citr
iol
1,25
(OH
) 2D
3 (p
g/m
L)
Stage 37.4 million
Stage 25.7 million
Stage 4300,000
CKD Stage 15.6 million
25
65
Low-Normal
Calcitriol
High-Normal PTH
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Feedback Loops in SHPT
Ca = calcium; CVD = cardiovascular disease; P = phosphorus.Courtesy of Kevin Martin, MB, BCh.
PTH
Bone DiseaseFracturesBone pain
Marrow fibrosisErythropoietin resistance
Serum P1,25D
Calcitriol
Renal Failure
PTH
Systemic ToxicityCVD
HypertensionInflammationCalcification
Immunological
25D
Ca++
Decreased Vitamin D Receptors and Ca-Sensing Receptors
© 2005 The Johns Hopkins University School of Medicine.
-2.25
-2.00
-1.75
-1.50
-1.25
-1.00
-0.75
-0.50
-0.25
0.00Spine Hip Arm
Bo
ne
Min
eral
Den
sity
, Z
-Sco
re
PTH <60 pg/mL PTH 60-120 pg/mL PTH >120 pg/mL
Bone Loss Correlates With Severity of SHPT in CKD Stages 3 and 4
*P<0.05 compared with patients with PTH in the normal range.Z-Score = comparison to the mean value for women at a similar risk, including age, weight, and ethnicity.Rix et al. Kidney Int. 1999;56:1084-1093.
*
**
© 2005 The Johns Hopkins University School of Medicine.
Bone-Fracture Rate Increases as CKD Progresses: Fractures in Patients on
Dialysis
*Ratio of observed incidence of hip fracture in patients with kidney failure to expected incidenceof hip fracture in the general population.Adapted from Alem et al. Kidney Int. 2000;58:396-399.
0
5
10
100
<45 45-54 55-64 65-74 75-84 TotalAge (y)
Ob
serv
ed/E
xpec
ted
In
cid
ence
of
Hip
Fra
ctu
re*
Male Relative Risk = 4.4Female Relative Risk = 4.4
Overall
15
20
80
100 8799
25 20
10 10
7.56.4
2.4 2.54.4 4.4
© 2005 The Johns Hopkins University School of Medicine.
Cardiovascular Outcomes Worsen With CKD Progression: 3-Y Follow-Up by eGFR
Levels
CHF = congestive heart failure.Anavekar et al. N Engl J Med. 2004;351:1285-1295.
0
10
20
30
40
50
60
CompositeEnd Point
Death FromCV Causes
Reinfarction CHF Stroke Resuscitation
Est
imat
ed E
ven
t R
ate
(%)
75 60-74 45-59 <45P<0.001
eGFR (mL/min/1.73 m2)
© 2005 The Johns Hopkins University School of Medicine.
Why Classify Severity as the Level of GFR?
AJKD 2002: 39(2)
Guideline 4.Estimation of GFR
AJKD 2002: 39(2)
Guideline 4.Estimation of GFR (cont’d)
AJKD 2002: 39(2)
Guideline 4.Estimation of GFR (cont’d)
AJKD 2002: 39(2)
Advantages of Estimating GFR Using Equations
AJKD 2002: 39(2)
Serum Creatinine Corresponding to GFR of
60 mL/min/1.73 m2
AJKD 2002: 39(2)
Relationship of Creatinine Clearance
and Serum Creatinine with GFR (Inulin Clearance) in
Patients with Glomerular Disease
AJKD 2002: 39(2)
Estimates of GFR vs. Measured GFR
in MDRD Study Baseline Cohort
AJKD 2002: 39(2)
Accuracy of Different Estimates of GFR in Adults
AJKD 2002: 39(2)
Prevalence of Individuals at Increased Risk for CKD
AJKD 2002: 39(2)
1.1 1.62.4 2.9
3.95.5
17.918.6
0
5
10
15
20
Pat
ien
ts W
ho
Are
Aw
are
of
Wea
k o
r F
ailin
g K
idn
eys*
(%
)
Awareness of Early-Stage CKD Is Low in the US Population
*Proportion of patients who were told they had weak or failing kidneys, eGFR (mL/min/1.73 m2). Coresh et al. J Am Soc Nephrol. 2005:16:180-188.
<30 30+ <30 30+ <30 30+ F MSex: Albuminuria:
eGFR: 90+ 60-89 30-59 30-59
© 2005 The Johns Hopkins University School of Medicine.
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.