Overview of Chronic Kidney Disease and ESRD

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Overview of Chronic Kidney Disease and ESRD

• Gordon McLennan, MD

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Conflicts Acknowledgments

• Member, Board of Trustees, The Renal Network Inc.
• Grant Support
• Boston Scientific Corporation
• Omnisonics Medical Technologies
• Cook, Inc.
• W. L. Gore, Inc.
• Arrow International

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Take Home Message

• CKD represents a much larger problem than ESRD
• Use of calculated GFR to assess renal function
  will help us identify patients at risk for ESRD
• It is incumbent on us to identify patients who
  can have fistulas placed at stage 3 4 CKD

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Chronic Kidney Disease ESRD

• ESRD (Renal Failure affects only about 400,000
  Americans
• Chronic Kidney Disease affects 8 Million

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Chronic Kidney Disease

• Glomerular filtration rate (GFR) lt60mL/min/1.73m2
  for gt3 months with or without kidney damage
  
• OR
• Kidney damage for gt3 months, with or without
  decreased GFR, manifested by either
• Pathologic abnormalities
• Markers of kidney damage, eg, proteinuria
• Affects 11 of US popluation

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CKD
Stage Description GFR Prevalence Prevalence
mL/min/1.73 m2 N (1000s)
0 At increase risk of CKD gt 90 20,000 11.2
1 Kidney damage w/ normal or ? GFR gt 90 5,900 3.3
2 Kidney damage w/ mild ? GFR 60-89 5,300 3.0
3 moderate ? GFR 30-59 7,600 4.3
4 severe ? GFR 15-29 400 0.2
5 Kidney Failure lt15 or dialysis 300 0.1

• Stages 0-4 NHANES III 1988-1994
• Stage 5 USRDS 1998

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Co-morbidities of CKD

• 50-500 x mortality
• Predominant cause is CVD

Foley RN, Parfrey PS, Sarnak MJ Clinical
epidemiology of cardiovascular disease in chronic
renal disease. Am J Kidney Dis 32S112-S119, 1998
(suppl 3)
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Incidence of End Stage Renal Disease (ESRD)
According to Primary Diagnosis
USRDS. 2004. Available at http//www.usrds.org/at
las.htm.
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Co-Morbidities of the ESRD Population

• 80 of dialysis patients who have an MI are dead
  within 3 years

Herzog CA, Ma JZ, Collins AJ Poor long-term
survival after acute myocardial infarction among
patients on long-term dialysis. N Engl J Med
339799-805, 1998
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Life Expectancy

• Patients Diagnosed with CKD DM Have a Greater
  Likelihood of Death than ESRD
• First nephrologist visit at an outpatient clinic
  (n20,363)

100 80 60 40 20 0
n11,698
3,637
2,884
2,144
Percent of patients ()
No Events
ESRD
Death
90.33
83.75
68.24
60.73
11.34
17.58
12.40
20.42
21.60
8.27
NDM/Non-CKD
DM/Non-CKD
NDM/CKD
DM/CKD
Status in the entry period
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CKD Principle 1

• There are close to 20 million patients in the
  U.S. with CKD stages 1-5. There are perhaps
  another 20 million patients in the U.S. at risk
  for CKD
• Many of these patients are not under a
  physicians care, so targeted screening of
  at-risk populations is cost-effective
• For those patients under a physicians care
  (usually a PCP), most of the CKD interventions
  can and should be delivered by the PCP
• Early referral of a CKD patient to a nephrologist
  (when GFR lt60 ml/min/1.73m2) to provide strategic
  guidance is associated with improved outcomes

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GFR

• Serum Creatinine is not very predictive of renal
  function
• GFR affected by age, gender, weight, race
• Formulas exist to estimate GFR that are more
  accurate than 24 hour urine collection
• MDRD
• GFR (mL/min/1.73 m2) 186 x (Scr)-1.154 x
  (Age)-0.203 x (0.742 if female) x (1.210 if
  African American)
• Crockroft-Gault
•    For men CrCl (140 - Age) x Weight
  (kg)/SCr x 72
•    For women CrCl ((140 - Age) x Weight
  (kg)/SCr x 72) x 0.85

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GFR
Lin J, Knight EL, Hogan ML, Singh AK A
Comparison of Prediction Equations for Estimating
Glomerular Filtration Rate in Adults without
Kidney Disease. J Am Soc Nephrol 14 25732580,
2003
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• 50 y/o AA Female referred from Family
  Practitioner for renal arteriography because of
  uncontrolled hypertension
• Significant history Type 2 DM Hypertention
• Serum Cr 1.4
• What would you do?

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• MRA
• Hydrate overnight
• Bicarb
• N-Acetyl Cystine
• Use alternative contrast agents
• Nothing specialDo arteriogram limit contrast
  as much as possible

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Calculated MDRD GFR

• GFR (mL/min/1.73 m2) 186 x (Scr)-1.154 x
  (Age)-0.203 x (0.742 if female) x (1.210 if
  African American)
• GFR 186 x 1.4-1.154 x 50-0.203 x 0.742 x 1.210

51
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CKD Principle 2

• Use of serum creatinine as a marker of kidney
  function grossly underestimates the presence and
  severity of CKD
• Formulas for GFR (MDRD) or creat. clearance
  (Cockcroft-Gault) are more sensitive, easy to use
  and do not require 24 hour urine collection
• 24 hour urine collection for creat. clearance is
  notoriously inaccurate
• All labs should be encouraged to report renal
  function as GFR based on MDRD formula (age,
  gender and race)

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Optimal CKD Patient Care
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Assessment for Renal Replacement Therapy

• Transplant
• Peritoneal Dialysis
• Hemodialysis
• AVF
• Graft
• Synthetic Material
• Biological Material (Bovine Carotid Artery)
• Catheter

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Fistula First

• CMS, the ESRD Networks, the renal community, and
  IHI will work together to increase the likelihood
  that every eligible patient will receive the most
  optimal form of vascular access for that patient.
  In the majority of cases, this will be a
  fistula.

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Incident Patients
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Prevalent Patients
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NVAII Goals

• By June 2006
• 40 prevalent fistulas
• 50 incident fistulas
• By June 2009
• 66 prevalent fistulas

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NVAII Change Concepts

1. Routine CQI review of vascular access
2. Early referral to nephrologist
3. Early referral to surgeon for AVF only
4. Surgeon selection
5. Full range of appropriate surgical approaches

1. AVF placement in catheter patients
2. Cannulation training
3. Monitoring and surveillance
4. Continuing education staff and patient
5. Secondary AVFs in AVG patients
6. Outcomes feedback

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Algorithms

• Venography or ultrasound in all catheter graft
  patients
• Look for conversions
• Algorithms to evaluate veins at Stage 3 4
• Physical Exam
• Ultrasound
• Venography where needed

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AVF Types
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Take Home Message

• CKD represents a much larger problem than ESRD
• Use of calculated GFR to assess renal function
  will help us identify patients at risk for ESRD
• It is incumbent on us to identify patients who
  can have fistulas placed at stage 3 4 CKD