CHRONIC KIDNEY DISEASE. Richard A. Schumacher, D.O. Nephrology and Hypertension

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1 CHRONIC KIDNEY DISEASE Richard A. Schumacher, D.O. Nephrology and Hypertension

2 DEFINITION The presence of kidney damage (usually detected as urinary albumin excretion of 30 mg/day, or equivalent) or Decreased kidney function (defined as estimated glomerular filtration rate [egfr] <60 ml/min per 1.73 m 2 ) for three or more months, irrespective of the cause.

3 CLASSIFICATION Cause of disease Six categories of egfr Three categories of albuminuria Provides a guide to management and risk stratification, counseling

4 HISTORY OF CKD The initial injury to the kidney may result in a variety of clinical manifestations, ranging from asymptomatic hematuria to renal failure requiring dialysis. Adaptive hyperfiltration Many individuals fully recover Some patients experience repeated and chronic insults (ie. Lupus, DM) The gradual decline in function in patients with chronic kidney disease (CKD) is initially asymptomatic

5 INCIDENCE Estimated >10% of adults (>20million) have CKD. The incidence of CKD is increasing most rapidly in people ages 65 and older. The incidence of recognized CKD in people ages 65 and older more than doubled between 2000 and The incidence of recognized CKD among 20- to 64- year-olds is less than 0.5 percent. Source: Centers for Disease Control and Prevention

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7 THE RISK OF KIDNEY DISEASE IS NOT UNIFORM Relative Risk Compared to Whites African Americans Native Americans Hispanic Americans 3.8 X 2.0 X 1.5 X USRDS, 2009

8 WHO TO TEST FOR CHRONIC KIDNEY DISEASE Regular testing of people at risk Diabetes Hypertension Relative with kidney failure Special alert for minority population

9 NEW CASES OF KIDNEY FAILURE BY PRIMARY DIAGNOSIS-2011, UNITED STATES RENAL DATA SYSTEM

10 MDRD LIMITATIONS The MDRD equation was NOT validated for: Children <18 years Seniors >75 years Normals or GFR >90 ml/min/1.73 m 2 Pregnancy Serious comorbid conditions Extremes of body size, muscle mass, nutritional status

11 WHEN DO I REFER MY PATIENT? Recommend referral when: Serum creatinine is over mg/dL 24hr Clcr is <50-60ml/min egfr <50ml/min Significant proteinuria (>1.0gm/24hrs) Steady rise in creatinine noted Unexplained hematuria -?uti, stones Uncontrolled edema, acid/base, or electrolyte disorder

12 MONITORING ALBUMINURIA How often? Albumin to creatinine ratio yearly in pts with DM. Confirm elevated ratio by testing at least 2x over next 3-6 months. Treatment should include ACE- or ARB for Htn. Should you start ACE- with normotensive pts??

13 THE COMPLICATIONS OF CRF ARE MULTIPLE Progression of renal disease Acceleration of cardiovascular disease Pericarditis Anemia Hypertension Neuropathies Renal osteodystrophy Secondary hyperparathyroidism Decreased immune system

14 ASSOCIATION WITH CARDIOVASCULAR DISEASE Among patients with CKD, the risk of death, particularly due to cardiovascular disease, is much higher than the risk of eventually requiring dialysis.

15 CKD CO-MORBIDITIES People with no CKD are more likely than people with stage 3 to 5 CKD to be alive 1 year after a heart attack. The 1-year mortality for heart attack patients without identified CKD is 36 percent, compared with 51 percent for patients with stage 3 to 5 CKD

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17 ASSOCIATION BETWEEN CKD AND CHD Independently associated with cardiovascular events. Chronic kidney disease and the risk for cardiovascular disease J Am Soc Nephrol. 2005;16(2):489. Associations of kidney disease measures with mortality and end-stage renal disease Lancet Nov;380(9854): Epub 2012 Sep 24. Impact of renal failure on the risk of myocardial infarction and death Kidney Int. 2002;62(5):1776.

18 CARDIOVASCULAR HEALTH STUDY The nine-year rates of cardiovascular death among 1899 individuals: History of myocardial infarction, but no diabetes or CKD: 15.7 percent History of diabetes, but no myocardial infarction or CKD: 15.8 percent History of CKD, but no myocardial infarction or diabetes: 13 percent The case for chronic kidney disease, diabetes mellitus, and myocardial infarction being equivalent risk factors for cardiovascular mortality in patients older than 65 years. Am J Cardiol Dec;102(12): Epub 2008 Oct 23.

19 NONTRADITIONAL RISK FACTORS Possible risk factors: Retention of uremic toxins Anemia Elevated levels of certain cytokines Increased calcium intake Abnormalities in bone mineral metabolism An "increased inflammatory-poor nutrition state

20 GENERAL MANAGEMENT Treatment of reversible causes Preventing or slowing the progression Treating complications Adjusting drug doses/vaccinations Preparation of the patient in whom renal replacement therapy will be required

21 REVERSIBLE CAUSES OF RENAL FAILURE Decreased renal perfusion prerenal Hypovolemia, hypotension, sepsis Nephrotoxic drugs intrarenal NSAIDS, iv contrast, antibiotics Urinary tract obstruction postrenal Nephrolithiasis, tumors, prostate

22 SLOWING THE RATE OF PROGRESSION Intraglomerular hypertension Glomerular hypertrophy (adaptive hyperfiltration) Glomerular scarring (glomerulosclerosis) Tubular sclerosis

23 RENAL PROTECTION Principal Targets: Attaining blood pressure goals Multifaceted plan Attaining proteinuria goals Ace-, Arb, Angiotensin -

24 WHAT BP MEDS SHOULD I START WITH? Individualized antihypertensive therapy: CHF ACE-, ARB, bblocker, lasix/aldactone Post MI ACE-, ARB, bblocker, aldactone CKD/Proteinuria Bblocker, ACE-, ARB, aldactone Angina Bblocker, calcium channel blocker A-fib Bblocker, non-dihydropyridine A-flutter Bblocker, non-dihydropyridine BPH Alpha blocker

25 UNCONTROLLED HYPERTENSION When should I get a renal Ultrasound? Would a Renal Artery Doppler study help? What other causes are there? Have I addressed every axis? Lower BP targets (<130/80) are associated with better renal outcomes in CKD pts with proteinuria > mg/24hrs.

26 RENAL PROTECTION CONT Additional Targets Protein restriction Statin therapy Smoking cessation Weight reduction Chronic metabolic acidosis

27 TREATING COMPLICATIONS OF CKD Volume Overload Hyperkalemia Metabolic Acidosis Mineral and Bone Disease Anemia Dyslipidemia Hypertension

28 TREATING COMPLICATIONS OF ESRD Protein-caloric Malnutrition Pericarditis Bleeding of uremia Neuropathy Infection risk

29 INFECTION AND VACCINATION Increased risk for infection (particularly lung and GU) KDIGO guidelines: All stages receive influenza vaccine. Stage 4-5 at risk for progression receive Hep B. All stage 4-5 receive pneumococcal vaccine.

30 PREPARATION FOR RRT Adequate preparation can decrease morbidity and perhaps mortality. Initiate at the optimal time. Recruitment and evaluation of family members. Psycological acceptance.

31 HOW WELL HAVE WE DONE? Thirty years ago: One third of diabetic patients were destined to develop kidney failure. Patients suffered from disabling bone disease, dementia caused by aluminum intoxication, and severe fatigue from uncontrollable anemia. Transplantation was not common, and acute rejection resulted in transplantation failure rates of 30 to 50 percent.

32 THIRTY YEARS AGO CONT No methods were available to screen diabetic patients for early signs of kidney injury, so preventive treatments were not possible. Few treatments for kidney disease were available, and the importance of controlling of blood sugar and blood pressure was not recognized. Kidney failure was increasing at epidemic rates. Through the 1980s and 1990s, the number of patients developing end-stage kidney failure nearly doubled each decade.

33 Today: HOW WELL HAVE WE DONE? With good care, fewer than 10 percent of diabetics develop kidney failure. Management of anemia and bone disease has markedly improved the quality of life. Dialysis dementia due to aluminum toxicity no longer occurs. Transplantation is widely available, although limited organ availability persists. One year survivability exceeds 90%.

34 TODAY CONT Kidney disease can be detected earlier by standardized blood tests to estimate renal function and monitoring of urine protein excretion New drugs better control blood pressure and slow the rate of kidney damage by about 50 percent. As a result of improved treatment, the number of new dialysis patients has stabilized, and indeed has begun to fall. An NIH education campaign informs patients and their doctors about the importance of early detection of kidney disease.

35 ESRD INCIDENT RATE

36 SURVIVAL RATES FOR DIALYSIS AND TRANSPLANT PATIENTS At 85.5 percent, the 5-year survival rate for transplant patients is more than twice the 35.8 percent survival rate for dialysis patients While graft survival is lower in African Americans than in Caucasians, patient survival rates are about equal

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38 THANK YOU