ESRD A Global Problem

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ESRD A Global Problem
UK 2002 19 300 dialysis 15 700 transplant
USA 2001 300 000 dialysis 80 000 transplant 12
billion/year
Germany1998 49 200 dialysis 15 400 transplant
Japan 1999 200 000 dialysis
Mortality on dialysis 20 p.a. Donor shortage
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Perception
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Abnormal renal function
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Steady state equation
Two elements Chronicity Damage
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Classification of CKD
RCPE Consensus meeting 2007 p suffix for
proteiniuria gt 1g/day Divide CKD stage 3 into
3a and 3b
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CKD is Highly Prevalent with Majority in Early
Stages
Stages of CKD
ESRD
CKD CARE
End Stage Renal Disease
Stage 5
Stage 4
Stage 3
Stage 2
Stage 1
gt90 ( kidney damage)
60-89
30-59
15-29
lt15 (or dialysis)
eGFR (mL/min/1.73m2)
It can be helpful to think of eGFR
(mL/min/1.73m2) as an approximation of kidney
function
Adapted from F Drüeke, WCN Presentation 2005
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The issues

• Its a lot of old people
• Yes it is
• It is a lot of work
• You do most of it already (and well)
• It is income generation
• No it isnt!

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Natural history

• Cardiovascular risk
• End stage renal failure

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Cardiovascular risk in ESRF
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Hallan et al BMJ 20063331047
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When to place vascular access?

• Ratio of unnecessary to necessary permanent
  access surgeries at different theoretical
  referral eGFR thresholds by age and length of
  follow-up.
• (a) Referral threshold eGFRlt25 ml/min/1.73 m2.
• (b) Referral threshold eGFRlt20 ml/min/1.73 m2.
• (c) Referral threshold eGFRlt15 ml/min/1.73 m2.

Kidney International (2007) 71, 555561. OHare
et al
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Defining renal risk
Cardiovascular death
Age
Renal death
A conceptual model
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Three things to measure
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Areas to consider

• Diagnosis
• DM, CVD, Drugs
• Progression
• eGFR
• Proteinuria and renal risk
• Complications
• Anaemia
• bones

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Referral

• Progression CKD 3
• CKD 4 and 5
• Complications
• Bones virtual
• Anaemia
• Intolerance of first line therapy
• Unclear aetiology (do renal USS)

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The main interventions

• Lifestyle
• Smoking
• Diet
• Exercise
• Blood pressure control
• ACEi and ARB
• Complications
• Anaemia
• Mineral metabolism
• Control of the underlying disease
• (Preparation for RRT)

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Treatment of Hypertension in Patients with CKD
Stages 1-4 Control of hypertension is the single
most effective intervention for slowing the rate
of decline in renal function of patients with
CKD. Target - Blood pressure should be lowered to
lt130/80 mmHg in all patients with CKD There is
some evidence that a lower target of lt125/75 mmHg
may provide additional benefit in patients with
gt1g/day of proteinuria (urine proteincreatinine
ratio gt1mg/mg or gt100mg/mmol)
Therapeutic agents Angiotensin-Converting Enzyme
Inhibitors (ACEIs) and Angiotensin Receptor
Blockers (ARBs) afford renal protection that is
in addition to their antihypertensive effects.
ACEI or ARB should therefore be regarded as
first-line antihypertensive therapy for all
patients with CKD click here for safety
guidance. The level of proteinuria is a strong
predictor of long-term renal prognosis. ACEI or
ARB dose should therefore be increased until
proteinuria has been decreased to lt1g/day (urine
proteincreatinine ratio lt1mg/mg or lt100mg/mmol).
If the blood pressure goal is not achieved with
maximum dose ACEI or ARB treatment, additional
antihypertensive treatment should be added to
lower blood pressure to target. A thiazide or
loop diuretic is often very effective if used in
combination with an ACEI or ARB, as the initial
additional agent. If the proteinuria goal is not
achieved with maximum dose ACEI or ARB,
combination ACEI and ARB therapy should be
considered. This should however be done only
under the supervision of the Renal Medicine Clinic
Taken from www.derby-egfr.co.uk
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Bonus areas

• Other considerations

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Medicines management

• Defining risk
• eGFR
• CKD 3 relative
• CKD 4 and 5 relative to absolute
  contraindications
• Advice to patients volume disturbance
• C-G
• dosing

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The vascular disease groupings
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Major Complications
The vascular triad
Diabetes
Lifestyle Blood Pressure Smoking Lipids Anaemia
CKD CVD
Diagnosis, Preparation, RRT
Diagnosis, Intervention
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Acute Kidney Injury
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The patient pathway

• A return to the start

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Vascular access pathway a surrogate for timely
preparation
Nephrology
Surgery
Maintenance
Detection
Research and clinical developments
CKD Projects
Planning the service Pilot sites and Joint
Working Party
Audit IT initiatives National and Renal
Registry projects Repeat survey MRSA Dataset
Improving patient outcomes Better RRT Reduced
morbidity
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• Overall 13,343 (77) of prevalent patients were
  having dialysis therapy delivered by definitive
  access.
• Centres varied from 52 to 95.
• For HD patients only, definitive access was used
  in 69, range from 44 to 94.

UK Incident patients April 2006 Time from renal
referral to RRT
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Why is CKD important?
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Perception is wrong
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