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Chronic Kidney Disease

Can dialysis be prevented?

Ron Gansevoort, nephrologist University Medical Center Groningen

The Netherlands

Brussels, March 5, 2013

Nr. of patients on Renal Replacement Therapy

284,000

1995 2000 2005 2010 2015

360,000 435,000

503,000 ~565,000

ERA-EDTA Registry

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Direct medical costs: ~21 billion Euro/yr

Calculated for the EU-27 countries

2. Dialysis is nowadays also started in elderly and frail patients, who were previously not accepted for dialysis

✚ Europe has an aging population

The number of patients on RRT increases EK

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3. Death rates due to cardiovascular disease have decreased. Consequently these patients now face the chronic complications of atherosclerosis: a.o. kidney failure

Why?

1. Changes in lifestyle have led to more diabetes and hypertension, the main causes for chronic kidney disease

How to prevent progression of CKD?

Kidney function

0%

10%

Follow-up (years)

0 1 2 3 4 5 6 7 8 9 10

Late intervention

Early intervention

Start dialysis

60%

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Can we detect CKD in an early phase?

Duration of diabetic kidney disease (years)

10

30

100

1.000

10.000

3.000

0

30

60

90

120

Urin

ary

prot

ein

loss

(mg/

d)

Kid

ney

func

tion

(%)

Normal

Moderately increased

Severely increased

Normal

Impaired

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Kidney function

Urinary protein loss

Dialysis

Incidence of Renal Replacement Therapy EK

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Urinary protein loss positive Urinary protein loss negative

0.01

0.1

1.0

10

100

1000

Kidney function (%) 0 30 60 90 120

Number of subjects starting RRT per 1000 screenees

Iseki et al, Am J Kidney Dis 2004

Screening the general population, n=95.252, follow-up: 7 years

Simple dipstick test:

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Matsushita et al, Lancet 2010, Gansevoort et al, Kidney Int 2011

Meta-analysis of 41 cohort studie including more than 1.5 million people

Incidence of (cardiovascular) mortality

Kidney function (%) Kidney function (%)

The new International Classification of CKD

Urinary protein loss

Kid

ney

func

tion

<30 mg/d

30-300 mg/d

>300 mg/d

>90%

60-90%

45-60%

30-45%

15-30%

<15%

No CKD (89%)

Mild risk (8%)

Moderate risk (2%)

High risk (~1%)

KDIGO Guidelines for Definition and Classification of CKD

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Kidney International 2013 Lever, Coresh, Matsushita and Gansevoort et al

CKD amplifies cardiovascular risk EK

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Atherosclerosis Coronary artery disease

Valvular disease Left ventricular hypertrophy

Decreased coronary perfusion Arrhytmias

Early CKD Kidney function >60% Urinary protein loss +

Mild to moderate CKD Kidney function 60 – 30%

Severe CKD Kidney function <30%

Gansevoort et al, Lancet (in press)

Acute kidney injury

27,5 32,9 41,1 48,858,0

34,6 28,125,9

24,4 7,5

37,9 39,0 33,0 26,8 34,5

0%10%20%30%40%50%60%70%80%90%

100%

Normal 60 - 45% 45 - 30% 30 - 15% <15% or RRT

Kidney function

OthersCancerCardiovascular

Causes of death in CKD EK

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Gansevoort et al, Lancet (in press)

Alberta Kidney Disease Network data Adjusted for age and gender N=949,119. Courtesy: Brenda Hemmelgarn

Kidney function

40,9

19,9

36,9

18,8

23,9

12,4

15,3

7,212,1

5,6

0

5

10

15

20

25

30

35

40

45

30 35 40 45 50 55 60 65 70 75 80

Age (years)

Normal kidney function

60 - 45%

45 - 30%

30 - 15%

<15% or RRT

Life

exp

ecta

ncy

(in

year

s)

Chronic Kidney Disease and life expectancy

Gansevoort et al, Lancet (in press)

Alberta Kidney Disease Network data N=949,119. Courtesy: Brenda Hemmelgarn

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Costs attributable to CKD

2012 Reports of the US MediCare and Renal Database System

Population Costs

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RRT 0.1% RRT 6.8%

Interventions to improve prognosis? EK

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Strict blood pressure control Lowering of urinary protein loss (RAASi)

Strict diabetes regulation Stop smoking Fight obesity

Use healthy food

Can cardiovascular disease in CKD be prevented?

medication diet

Strict blood pressure control Strict diabetes regulation

Lowering cholesterol Stop smoking Fight obesity

Use healthy food

diet medication

Food and CKD EK

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Medication and food interact EK

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Kidney Events

Cardiovascular events

Normal blood pressure lowering agents

Normal blood pressure lowering agents

RAAS inhibitors

RAAS inhibitors

Lambers Heerspink et al, J Am Soc Nephrol 2012

RENAAL / IDNT studies, N=1177 patients Diabetic kidney disease, protein loss > 300 mg/d

Prevention works !!! EK

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2012 Report of the US Renal Database System Adjusted for age and gender

Patient awareness of early CKD is low EK

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than 30% function Less

than 30% function

Less than 10% function

no symptoms

life threatening

symptoms

Fatigue

Itching

Nausea

Loss of appetite

Weight loss

Screening for early CKD is inadequate EK

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2012 Report of the US Renal Database System

Kidney function Urinary protein loss

Both tests

50

55

60

65

70

75

80

85

90

95

100

Normal 60-45 45-30 30-15 <15 orRRT

Kidney function (%)

AspirinNovel platelet blockersBeta-blockerStatin

Therapeutic nihilism in CKD EK

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50

55

60

65

70

75

80

85

90

95

100

Normal 60-45 45-30 30-15 <15 orRRT

Kidney function (%)

Smoking cessation Cardiac rehabilatationDietExercise

Fox et al, Circulation 2010

N=30.462 Registry of patients admitted to a coronary care unit

Drug treatment at discharge

Life style advice at discharge

Percentage Percentage

TAKE CARE

BETTER START WORKING!

DOCTORS

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We need guidelines

Key Messages EK

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- Late stage CKD, with need for renal replacement therapy - Early stage CKD, with a high risk for cardiovascular events

High burden of disease for subjects involved (QoL and morbidity) and for the society at large (costs).

Prevention is possible, but we need to increase awareness among doctors and patients to improve early identification of high risk patients, in whom treatment should be started.

MEPs can help: - Implement guidelines, especially for general practice - Implement screening programs - Regulation of food industry, and influencing healthy behavior - Stimulate research (Horizon 2020)