Slowing the Progression of Chronic Kidney Disease

Lawrence Fleming, M.D.

August 9, 2006

Objectives

• Definitions and course of chronic kidney disease (CKD).

• Statistics- the prevalence of CKD.• Diagnosis of CKD.• Stratification of CKD.• Clinical plan for CKD.• Evaluation and treatment.• Interventions for slowing progression of CKD.• Disease management in CKD.

Definition and Course of CKD

“Chronic kidney disease” includes the conditions that affect the kidney with the potential to cause either progressive loss of kidney function or complications resulting from decreased kidney function.

“Kidney damage” is structural or functional abnormalities of the kidney initially with normal GFR, which overtime can lead to decreased GFR.

From: Kidney Disease Outcome Quality Initiative (K/DOQI) clinical practice guidelines for CKD.

Definition and Course of CKD

Definition and Course of CKD

Statistics- the Prevalence of CKD

• In the US, 400,000 patients have end-stage renal disease (ESRD); 11% of adults are in earlier stages of CKD.

• Yearly mortality rate of patients with ESRD is 20%.

• Patients with CKD have a risk of CV disease that is 10-30 times that of people with no kidney disease.

Statistics- the Prevalence of CKD

• Diabetes is the most common cause of CKD and accounts for one-half of new cases of ESRD.

Diagnosis of CKD

• The most sensitive test for early kidney disease is urine albumin (normal daily albumin excretion for an adult is 10 mg).

• Using data from patients enrolled in the Modification of Diet in Renal Disease (MDRD) study and stepwise regression analysis, an equation was developed that predicts GFR from serum creatinine, age, gender, and ethnicity.

Diagnosis of CKD

Stratification of CKD

Clinical Plan for CKD

Evaluation and Treatment

• Evaluate patients to determine:– Diagnosis (cause of kidney disease)– Present level of kidney function and risk for

further loss of kidney function– Comorbidities, especially cardiovascular– Complications of kidney disease (anemia,

calcium/phosphorus homeostasis, neuropathy, etc.)

– Risk of CV disease

Evaluation and Treatment

• Treatment should include:– Provide specific therapy based on the

diagnosis– Manage comorbitities, especially CV disease– Slow subsequent loss of kidney function– Prevent and/or treat complications of the

kidney disease.– Prepare for kidney replacement therapy

Interventions for Slowing Progression of CKD

Interventions Shown to Slow Progression of CKD

• Aggressive glycemic control in patients with diabetes

• ACE-inhibitors or angiotensin-receptor blockers

• Aggressive blood pressure control

Disease Management of CKD

• Identify patients with CKD electronically if possible (lab data, claims data).

• Verify the CKD diagnosis.

• Consent of PCP and/or nephrolgist to enroll patient in disease management program.

• Enter patient data into registry for tracking and management.

Disease Management of CKD

• Nurse manager contacts patient for assessment (renal history, risk stratification, comorbidities, etc.).

• Team constructs management plan for the patient.

• Monitor progression of CKD and management of comorbidities.