Chronic Kidney Disease

1
Chronic Kidney Disease

• Hasan Khamash MD
• Assistant Professor of Medicine
• KCOM

2
ESRD Rates Continue to Rise
USRDS, 2004
3
Prevalence of Renal Insufficiency in U.S.
Thus, about 8 million Americans have a GFR less
than 60 mL/min/1.73 m2. Plus 11 million more
have a GFR over 60 but have persistent
microalbuminuria.
Coresh, et al., 2005
4
(No Transcript)
5
Incident Counts Adjusted Rates, By Primary
Diagnosis

USRDS, 2004
6
The Risk of Kidney Failure is Not Uniform

• Relative risks compared to Whites
• African Americans 3.8 X
• Native Americans 2.0 X
• Asians/Pacific Islander 1.3 X
• The relative risk of Hispanics compared to
• non-Hispanics is about 1.5 X

USRDS, 2004
7
(No Transcript)
8
Kidney Failure Compared to Cancer Deaths in the
U.S. in 2000(in Thousands)
Seer, 2004
9
(No Transcript)
10
CKD Predicts CVD
Age-Standardized Rate of Cardiovascular Events
(per 100 person-yr)
Estimated GFR (mL/min/1.73 m2)
Go, et al., 2004
11
Costs of Kidney Failure are High(in billions
for 2002)

USRDS, 2004
12
(No Transcript)
13
Prevalence of Renal Insufficiency in U.S.
Thus, about 8 million Americans have a GFR less
than 60 mL/min/1.73 m2. Plus 11 million more
have a GFR over 60 but have persistent
microalbuminuria.
Coresh, et al., 2005
14
CKD is Not Being Recognized or Treated

• Most practices screen fewer than 20 of their
  Medicare patients with diabetes
• Patients are referred late to a nephrologist,
  especially African-American men
• Less than 1/3 of people with identified CKD get
  an ACE Inhibitor

Kinchen, et al., 2002 McClellan et
al.,1997 Data provided by the USRDS based on 5
percent Medicare enrollment and claims data
15
Treatment to Prevent Progression of CKD to Kidney
Failure

• Intensive glycemic control lessens progression
  from microalbuminuria in type 1 diabetes
• - DCCT, 1993
• Antihypertensive therapy with ACE Inhibitors
  lessens proteinuria and progression
• - Giatras, et al., 1997
• - Psait, et al., 2000
• - Jafar, et al., 2001
• Low protein diets lessen progression
• - Fouque, et al., 1992
• - Pedrini, et al., 1996
• - Kasiske, et al., 1998

Meta-Analyses

Meta-Analyses
16
(No Transcript)
17
(No Transcript)
18
(No Transcript)
19
(No Transcript)
20
(No Transcript)
21
Plasme Creatinine and GFR
22
(No Transcript)
23
(No Transcript)
24
(No Transcript)
25
(No Transcript)
26
(No Transcript)
27
(No Transcript)
28
(No Transcript)
29
(No Transcript)
30
(No Transcript)
31
(No Transcript)
32
(No Transcript)
33
(No Transcript)
34
(No Transcript)
35
(No Transcript)
36
(No Transcript)
37
(No Transcript)
38
Other Measures

• Avoid nephrotoxic Meds.
• Address the possibility for bladder outlet
  problems.
• Volume over load ? Na restriction, Loop diuretic.
• Hyperkalemia ? K restriction, Loop diuretic if
  volume overloaded, Kayexalate.

39
(No Transcript)
40
(No Transcript)
41
Contrast Induced Nephropathy

• A small rise in the plasma creatinine
  concentration (averaging 0.2 mg/dL) is a common
  occurrence after a radiocontrast study.
• Risk Factors
• Underlying renal insufficiency, Cr1.5 mg/dL or
  GFR
• Diabetic nephropathy with renal insufficiency
• Hypovolemia true or effective.
• High total dose of contrast agent.
• Multiple myeloma.

42
Recommendation

• Identify high risk patients esp. DM with GFR
• Use other modalities if possible.
• Avoid hypovolemia and NSAIDs.
• Low or iso-osmolal dye with least amount
  possible. Mix with gadolinium.
• NAC 600 mg BID day before and of test.
• HCO3 drip.
• Possible role for high dose or IV NAC and
  hemofiltration esp for DM with Cr 4.

43
(No Transcript)
44
(No Transcript)
45
Early referral to nephrologist

• An informed selection of dialysis modality
• Timely placement of appropriate dialysis access
• Earlier initiation of dialysis
• Lower morbidity and improved rehabilitation
• Slower progression of kidney failure
• Less frequent and shorter hospital stays
• Lower cost
• Improved survival

46
Causes for late referrals

• Unaviodable cause ARF, patient refusing referral
  due to fear of dialysis.
• Referral biases of physicians.
• Lack of training regarding timing or
  indications.
• Poor communications between physicians.
• Economic factors (fear of losing patients)
• Structure of the health care system HMO related.

47
(No Transcript)
48
(No Transcript)
49
(No Transcript)