1 Definition, Prevalence, Pathophysiology and Complications of CKD JM Krzesinski CHU Liège-ULg Core curriculum Nephrology September 28 th 2013
2 KI supplements January 2013
3 Objectives of the course on CKD: To know 1. The definition 2. The main risk factors 2. The manner to diagnose and to grade 3. The etiology 4. The pathophysiology 5. The possible complications
4 Case history Mr RB, 69 years old, Type II diabetes for 15y, HTN, dyslipidemia BMI 28 Kg/m², sitting BP 150/80 mmhg Biology:serum creatinine 1.8 mg/dl, proteinuria 400 mg/g urin creat,no hematuria Treatment: Atenolol, gliclazide, metformin, simvastatin CKD? Related to diabetes? Risk for progression? Complications?
5 Diagnosis and management of CKD The diagnostic procedure includes 5 steps: 1. Confirming the CKD status 2. Precising the stage 3. Establishing the cause 4. Evaluating the progression rythm and identifying its factors 5. Evaluating the complications and trying to limit their consequences
6 Definition of CKD
7 Which egfr equation to use?
8 Measurement of e GFR (Iphone, smartphone)
9 Evaluation of RB s egfr MDRD or CKD EPI 38 ml/min per 1.73m² But 1 year ago: 45 ml/min per 1.73m² So CKD confirmed!
10 Staging CKD
11 Proteinuria Use albumin/creatinine ratio (ACR) (more sensitive at low levels) ACR in diabetes Protein/creatinine ratio (PCR) may be used for quantification and monitoring Here 400 mg PCR
13 Who needs a renal ultrasound? All people with Increase of serum creatinine Haematuria Proteinuria Obstructive symptoms > 20 yrs with FHx polycystic kidneys Prior to biopsy Here this exam is still normal
14 Prevalence CKD 11.5% or 6.7%
15 Case history Mr RB, 69 years old, Type II diabetes, HTN,dyslipidemia for 15y Biology: serum creatinine 1.8 mg/dl, proteinuria 400 mg/g urin creat, no hematuria Cause of CKD?
16 Risk Factors for CKD development Age (>60y) Hypertension Diabetes mellitus Obesity (BMI >30Kg/m²), MS (Hyperuricemia) Urological problems Reduced kidney mass (Low birth weight) Family or personal history of KD (Gnitis,AKI) Use of nephrotoxics (profession, medications) Chronic diseases (CV, infection, auto-immune) Low incomes, low education
17 Case history MDRD or CKD EPI 38 ml/min per1.73m² (but 1 year ago, 45 ml/min). So CKD confirmed! What is the cause? Presence of retinal lesions due to diabetes, no hematuria, and 15y history of DM: So it is a probable DN (renal biopsy unneeded!)
19 Pathophysiology of CKD The initial lesions could affect each part of the kidney. The evolution could be complete healing, but also either only partial or no recovery.
20 Case history Mr RB, 69 years old, Type II diabetes, HTN,dyslipidemia for 15y Biology: serum creatinine 1.8 mg/dl, proteinuria 400 mg/g urin creat, no hematuria Risk for progression?
21 Mechanisms of progression of CKD
23 Jungers P. et al., Nephrol Dial Transplant, 1995, 10,
26 Clinical predictors of accelerated progression of renal disease HUNSICKER, Kidney Int., 1997, 51, 1908 Ritz, Kid Int., 2000 Greater proteinuria Higher BP Black race Diabetes Lower serum HDL chol Smoking High dietary proteins
27 Influence of Brachial SBP and PWV (Weir M et al CJASN 2011; 6: 2403) or of natriuresis on proteinuria (Weir M et al Am J Nephrol 2012; 36: 397)
28 Progression of CKD
37 Brenner B., Kidney Int, 2003, 64.
38 NDT 2002
44 Identify progressive CKD Obtain minimum 3 GFRs over not less than 90 days If new finding low GFR, repeat within 2 weeks to exclude ARF
45 Identify progressive CKD Obtain minimum 3 GFRs over not less than 90 days If new finding low GFR, repeat within 2 weeks to exclude ARF Define progression as GFR fall > 5 ml/min /yr or 10 ml/min in 5 yrs Extrapolate current rate of decline: will pts need RRT in their life time?
46 Extrapolate current rate of decline: will pt need RRT in their life time? 1. Will their kidneys fail in their lifetime? 2. Will they die of something else first?
47 Ranking for adjusted relative risk for various outcomes Kidney International 2011 Levey, Eckardt Gansevoort; KI 2011 Meta-analysis of 45 cohorts n= with 5 years of follow-up
51 Case history Mr RB, 69 years old, Type II diabetes, HTN,dyslipidemia for 15y Biology: serum creatinine 1.8 mg/dl, proteinuria 400 mg/g urin creat, no hematuria S Ca 8.8 mg/dl; P 3.5 mg/dl; albumin 4 g/dl and s bicarbonate 25 mmol/l Risk for ESRD at 2y: 3.7% and at 5y: 11.6% (intermediate risk)
52 The majority of patients with CKD 1-3 do not progress to ESRD. Their risk of cardiovascular death is higher than their risk of progression.
FREQUENTLY ASKED QUESTIONS ABOUT GFR ESTIMATES TABLE OF CONTENTS MEASUREMENT OF KIDNEY FUNCTION 4 1) What is GFR? 4 2) How is GFR measured? 4 3) What does GFR indicate? 4 4) Why measure GFR as an index
162..194 NEPHROLOGY 2010; 15, S162 S194 doi:10.1111/j.1440-1797.2010.01240.x Prevention and management of chronic kidney disease in type 2 diabetes Date written: April 2009nep_1240 Final submission: April
hapter 16 Kidney Diseases in Diabetes Robert G. Nelson, MD, MPH; William. Knowler, MD, DrPH; David J. Pettitt, MD; and Peter H. Bennett, MB, FRP, FFM SUMMARY Diabetes now accounts for ~35% of all new cases
High Blood Pressure and Chronic Kidney Disease For People with CKD Stages 1 4 www.kidney.org National Kidney Foundation's Kidney Disease Outcomes Quality Initiative Did you know that the National Kidney
definition and diagnosis of diabetes mellitus and intermediate hyperglycemia Report of a WHO/IDF Consultation WHO Library Cataloguing-in-Publication Data Definition and diagnosis of diabetes mellitus and
WHO/NMH/MNC/03.1 Original: English Screening for Type 2 Diabetes Report of a World Health Organization and International Diabetes Federation meeting World Health Organization Department of Noncommunicable
STATE OF THE NATION Challenges for 2015 and beyond England The state of the nation: diabetes in 2014 4 Care for children and young people 28 The challenges for 2015 and beyond: what needs to happen over
Diabetes and Endocrine Health Network Type 2 diabetes in Children and Adolescents Model of Care and Clinical Practice Guideline for Western Australia Developed by the Department of Diabetes and Endocrinology,
DCCT and EDIC: The Diabetes Control and Complications Trial and Follow-up Study National Diabetes Information Clearinghouse U.S. Department of Health and Human Services NATIONAL INSTITUTES OF HEALTH What
AMERICAN GERIATRICS SOCIETY CONSENSUS STATEMENT Vitamin D for Prevention of Falls and their Consequences in Older Adults Developed by the Workgroup of the Consensus Conference on Vitamin D for the Prevention
1 Chronic Conditions Among Older Americans Chronic Illness on the Rise How Much Do We Spend on Chronic Conditions? A Closer Look at Selected Chronic Conditions 9 Chronic Conditions among Older Americans
T h e n e w e ng l a nd j o u r na l o f m e dic i n e original article Blood Glucose Control and Vascular Outcomes in Patients with Type 2 Diabetes The ADVANCE Collaborative Group* A bs tr ac t The members
Focus on PSA Screening for Prostate Cancer Vol. 28 Supplement, February 2012 Prostate Cancer: Should We Be Screening? INSIDE THIS ISSUE 2 Why the Controversy? 3 Active Surveillance 4 The Radical Prostatectomy
NATIONAL DIABETES INFORMATION CLEARINGHOUSE Am I at Risk for type 2 Diabetes? Taking Steps to Lower the Risk of Getting Diabetes U.S. Department of Health and Human Services National Institutes of Health
Life after gestational diabetes (GDM) 1 EAT WELL 2 PLAY WELL 3 STAY WELL Reduce your risk of diabetes - information for all the family This booklet is to help you, women who have had gestational diabetes
American Kidney Fund reaching out giving hope improving lives High Blood Pressure and Your Kidneys reaching out giving hope improving lives High Blood Pressure: The #2 Cause of Kidney Failure Your doctor
Testing for Prostate Cancer Should I be tested? Is it the right choice for me? Prostate cancer affects many men. There are tests to find it early. There may be benefits and risks with testing. Research
National Cholesterol Education Program High Blood Cholesterol What you need to know Why Is Cholesterol Important? Your blood cholesterol level has a lot to do with your chances of getting heart disease.
ACE/AACE Consensus Statement Diagnosis and Management of Prediabetes in the Continuum of Hyperglycemia When Do the Risks of Diabetes Begin? A Consensus Statement From the American College of Endocrinology
Clinical practice guidelines: Type 1 diabetes in children and adolescents Prepared by the Australasian Paediatric Endocrine Group for the Department of Health and Ageing APPROVED BY THE NHMRC ON 9 MARCH
Biomedical Ethics Readings Page 16/80 SHOULD ALCOHOLICS COMPETE EQUALLY FOR LIVER TRANSPLANTATION? Alvin H. Moss and Mark Siegler [From Journal of the A nierica a Medical Association Vol. 265, 1296-1298.
National Evidence-Based Clinical Care Guidelines for Type 1 Diabetes in Children, Adolescents and Adults Commonwealth of Australia 2011 Printed document This work is copyright. You may reproduce the whole