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Chronic Kidney Disease-Related Mineral and Bone Disorder: Public Health Problem. Kerry Willis PhD National Kidney Foundation. Dialysis. All ESRD. Cadaveric Transplant. Living Related Transplant. Adjusted 1st Year Patient Death Rates by Treatment Modality and Year of Incidence, 1986-96.

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chronic kidney disease related mineral and bone disorder public health problem

Chronic Kidney Disease-Related Mineral and Bone Disorder:Public Health Problem

Kerry Willis PhD

National Kidney Foundation

slide2

Dialysis

All ESRD

Cadaveric Transplant

Living Related Transplant

Adjusted 1st Year Patient Death Rates by Treatment Modality and Year of Incidence, 1986-96

Deaths/100 patient-years

21.5

19.8

4.1

2.0

Year of ESRD Incidence or Transplantation

1999 annual report of the US Renal Data System

slide3

Cardiovascular Mortality in the General Population and in Dialysis Patients

General population

Dialysis population

Male

Black

Male

Black

Female

Female

White

White

100

10

1

Annual mortality (%)

0.1

0.01

25–34

35–44

45–54

55–64

65–74

75–84

85

Age (years)

nkf s clinical practice guidelines
NKF’s Clinical Practice Guidelines
  • Evidence Based Review
  • Publication and Dissemination
  • Implementation
  • Reassess Impact
  • Update
slide5

1997

1999

2005

DOQI

K/DOQI

KDIGO

Dialysis

Anemia

Access

Nutrition (00)

Dialysis (’01)*

Anemia (’01)*

Access(‘01)*

CKD class. (’02)

Bone/Mineral (’03)

Lipids (’03)

Htn (’04)

CV (’05)

Diabetes (’07)

Hep C (’08)

Bone/Mineral (’08)

*updates

http://www.kidney.org/professionals/kdoqi

http://www.kdigo.org/welcome.htm

nkf k doqi definition of ckd
NKF-K/DOQI Definition of CKD

Structural or functional abnormalities of the kidneys for >3 months, as manifested by either:

1. Kidney damage, with or without decreased GFR, as defined by

  • pathologic abnormalities
  • markers of kidney damage
    • urinary abnormalities (proteinuria)
    • blood abnormalities (renal tubular syndromes)
    • imaging abnormalities
  • kidney transplantation

2. GFR <60 ml/min/1.73 m2, with or without kidney damage

ckd is a public health problem
CKD is a Public Health Problem
  • CKD is common
  • CKD is harmful
  • We have treatment
slide9

7.7 m

11.3 m

5.6%

7.7 m

3.8%

0.3 m

0.2%

Conceptual Model for CKD

Complications

Normal

Increasedrisk

Damage

 GFR

Kidneyfailure

CKDdeath

Screening for CKDrisk factors:

diabeteshypertension

age >60family history

US ethnic minorities

CKD riskreduction;Screening forCKD

Diagnosis& treatment;Treat comorbidconditions;Slow progression

Estimateprogression;Treatcomplications;Prepare forreplacement

Replacementby dialysis& transplant

k doqi clinical practice guidelines on bone metabolism and disease in chronic kidney disease

K/DOQI Clinical Practice Guidelineson Bone Metabolism and Diseasein Chronic Kidney Disease

Published October 2003

kdoqi clinical practice guidelines for bone metabolism and disease in chronic kidney disease
KDOQI Clinical Practice Guidelines for Bone Metabolism and Disease in Chronic Kidney Disease

Chair: Vice-Chair:

Shaul G. Massry, MD Jack W. Coburn, MD

KECK School of Medicine VA Greater Los Angeles

Work Group Members:

Glenn M. Chertow, MD, MPH James T. McCarthy, MD

University of California, San Francisco Mayo Clinic

Keith Hruska, MD Sharon Moe, MD

Barnes Jewish Hospital Indiana University

Craig Langman, MD Isidro B. Salusky, MD

Children’s Memorial Hospital UCLA School of Medicine

Hartmut Malluche, MD Donald J. Sherrard, MD

University of Kentucky VA Puget Sound

Kevin Martin, MD, BCh Miroslaw Smogorzewski, MD

St. Louis University University of Southern California

Linda M. McCann, RD, CSR, LD Kline Bolton, MD

Satellite Dialysis Centers RPA Liaison

treatment recommendations stages 3 4
Treatment Recommendations(Stages 3 & 4)
  • Decrease total body phosphorus burden by dietary restriction and phosphorus binder therapy- 2.7- 4.6 mg/dL; begin when EITHER elevated serum phosphorus OR elevated serum PTH
  • Treat elevated PTH with active oral vitamin D sterol to target of 35-70 (CKD 3) or 70-110 (CKD 4) pg/mL by intact assay
  • Normalize serum calcium
treatment recommendations stage 5 dialysis
Treatment RecommendationsStage 5 (dialysis)
  • Normalize serum phosphorus by diet and phosphorus binder therapy-3.5-5.5 mg/dL (1.13 -1.78 mmol/L); limit elemental calcium intake from binders to 1500 mg/day
  • Treat elevated PTH with active vitamin D sterol to target of 150-300 pg/mL (16-32 pmol/L) by intact assay
  • Normalize serum calcium- ideally 8.4 -9.5 mg/dL (2.10-2.38 mmol/L), and always < 10.2 mg/dL (2.55 mmol/L); Ca X P < 55 mg2/dL2
slide16

Homocysteine

Traditional Risk Factors

Non-traditional Risk Factors

Diabetes

Elevated IL-1, Il-6, TNFa

Smoking

Genetics

Oxidation (OxLDL)

HTN

Advanced glycation

end-products

Age

Dyslipidemia

Carbonyl stress

Cardiovascular disease in CKD

Fractures

Low fetuin-A

Abnormal bone

Abnormal mineral metabolism

classification issues in bone and mineral disorders
Classification Issues in Bone and Mineral Disorders
  • The term renal osteodystrophy is used to describe different entities
  • The predominant use is to describe a disorder of bone remodeling. However this does not take into account new data that there is increasedmorbidity/mortalityof abnormal serum biochemistries (i.e. phosphorus), nor increased awareness of vascular disease related to bone and mineral disorders in CKD patients.
slide18

Definition, Evaluation and Classification

of Renal Osteodystrophy:

A position statement from Kidney Disease

Improving Global Outcomes (KDIGO)

April, 2006

standardization of terms
Standardization of Terms
  • The term renal osteodystrophy (ROD)should be used exclusively to define the bone pathology associated with CKD.
  • The clinical, biochemical, and imaging abnormalities should be defined more broadly as a clinical entity or syndrome called Chronic Kidney Disease-Mineral and Bone Disorder (CKD-MBD).
definition of ckd mbd
Definition of CKD-MBD

A systemic disorder of mineral and bone metabolism due to CKD manifested by either one or a combination of the following:

  • Abnormalities of calcium, phosphorus, PTH, or vitamin D metabolism
  • Abnormalities in bone turnover, mineralization, volume, linear growth, or strength
  • Vascular or other soft tissue calcification

Moe et al Kidney International June 2006

summary
Summary
  • CKD is defined using eGFR and classified into 5 stages
  • This classification can help predict clinical outcomes
  • Early detection and treatment can improve patient outcomes
  • There is a link between CVD and bone and mineral disease in CKD
  • New CKD-MBD classification will form the basis for

updated, international clinical practice guidelines

population attributable risk of all cause mortality in ckd 5d
Population Attributable Risk of All Cause Mortality in CKD 5D
  • 17.5% Mineral metabolism abnormalities (Phosphorus > 5.0 mg/dl, Calcium > 10 mg/dl, intact PTH > 600 pg/ml)
  • 11.3% Anemia (hgb < 11 g/dl)
  • 5.1% Inefficient Dialysis (URR < 65%)

Corollary: We should be able to significantly improve mortality of CKD patients by improving control of mineral metabolism

Block et al JASN 2004