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New Concepts in Chronic Kidney Disease. Jonathan B. Jaffery, MD Assistant Professor of Medicine University of Wisconsin-Madison. New Concepts in Chronic Kidney Disease. The Epidemic Estimating GFR & Staging Risk factors for progression Role of Angiotensin II Management.

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new concepts in chronic kidney disease

New Concepts in Chronic Kidney Disease

Jonathan B. Jaffery, MD

Assistant Professor of Medicine

University of Wisconsin-Madison

new concepts in chronic kidney disease1
New Concepts in Chronic Kidney Disease
  • The Epidemic
  • Estimating GFR & Staging
  • Risk factors for progression
  • Role of Angiotensin II
  • Management
patient awareness of ckd
Patient awareness of CKD

Proportion of individuals who were ever told that they had weak or failing kidneys by the level of GFR (ml/min per 1.73 m2), elevated urinary albumin to creatinine ratio (ACR; mg/g) and gender.

Coresh et al, JASN 16: 180-188, 2005

slide6

Estimating GFR

  • Cockcroft-Gault Equation1
  • MDRD Equation2

GFR(ml/min/1.73m2)=

170 (Scr)-0.999(Age)-0.176(SUN)-0.170(Alb)+0.318

(0.762 if female)(1.180 if black)

(140-Age)(Weight)

Ccr(ml/min)=

(0.85 if female)

72(Scr)

1 Cockcroft and Gault, Nephron 1976 2 Levey et al, Ann Intern Med 1999

estimating gfr
Estimating GFR
  • Modified MDRD equation
    • e-GFR = 186 x (PCR)-1.154 x (Age)-0.203 x (0.742 if female) x (1.210 if African American)
  • Convince the lab to do it automatically
  • On-line e-GFR calculators
    • http://www.nkdep.nih.gov/healthprofessionals/tools/gfr_adults.htm
    • http://www.kidney.org/kls/professionals/gfr_calculator.cfm
ckd staging
CKD Staging

K/DOQI guidelines, AJKD, Vol. 39, No 2, Suppl 1, February 2002

chronic kidney disease progression risks
Chronic Kidney Diseaseprogression risks
  • Hypertension
  • Proteinuria
  • Glycemic control
  • Smoking
  • Lipids
measuring proteinuria
Measuring proteinuria
  • The ratio of protein or albumin to creatinine in an untimed (spot) urine sample is an accurate alternative to measurement of protein excretion in a 24-hour urine collection.
ckd progression risks glycemic control
CKD Progression Risks glycemic control

Cumulative Incidence of Urinary Albumin Excretion {300 mg per 24 Hours (Dashed Line) and 40 mg per 24 Hours (Solid Line)} in Patients with IDDM Receiving Intensive or Conventional Therapy.

Diabetes Control and Complications Trial Research Group, N Engl J Med 329:977, 1993

ckd progression risks smoking
CKD Progression Risks smoking

Mean calculated glomerular filtration rate (GFR) at each year after study entry during the 5-year follow-up in smokers (—•—) versus nonsmokers (—     —) with established diabetic nephropathy.

*P < 0.03 versus nonsmokers.

ckd progression risks lipids
CKD Progression Risks lipids
  • Samuelsson O et al, Nephrol Dial Transplant. 1997 Sep;12(9):1908-15
ace inhibitors and ckd progression meta analysis
ACE Inhibitors and CKD ProgressionMeta-analysis
  • 11 randomized controlled trials comparing ACE inhibitors vs. other medications in treatment of hypertension in 1860 nondiabetic patients with CKD (S Cr=2.3).
  • Results:
    • ACE inhibitors lowered BP and proteinuria.
    • ACE inhibitors decreased the combined risk of progression of CKD and development of ESRD by 30%, independent of BP lowering effects.

Jafar T, Ann Intern Med 135:73-87, 2001

slide19

ACEi/ARB

100

GFR

80

60

40

20

0

Time

acei arb and gfr
ACEi/ARB and GFR

60

100

Heart Rate

50

80

40

GFR

60

30

40

20

20

10

0

0

b-Blocker

ACEi/ARB

chronic kidney disease management
Slow the progression

• Blood pressure • Smoking

• Proteinuria• Lipids

• Protein restriction • Glycemic control

Evaluate and treat complications

• Anemia • Osteodystrophy

Prepare for renal replacement therapy

• Vascular access • Referral to Nephrology

Chronic Kidney Disease management
chronic kidney disease management1
Chronic Kidney Disease management
  • National Kidney Foundation Kidney Disease Outcome Quality Initiative (K/DOQI)
    • The Kidney Disease Outcomes Quality Initiative or K/DOQI provides evidence-based clinical practice guidelines developed by volunteer physicians and health care providers for all stages of chronic kidney disease and related complications, from diagnosis to monitoring and management.
    • http://www.kidney.org/professionals/kdoqi/index.cfm
i slowing the progression of ckd proteinuria
I. Slowing the progression of CKD Proteinuria
  • ACEi or ARB
  • Nondihydropyridine calcium channel blockers (verapamil and diltiazem)
    • have been shown to effective in reducing urinary albumin excretion, beyond ability to lower blood pressure

(Bakris GL et al, Kidney Int. 2004 Jun;65(6): 1991-2002)

  • Combinations?
i slowing the progression of ckd protein restriction
I. Slowing the progression of CKD Protein Restriction
  • Animal studies - dietary protein restriction significantly slows development of renal disease
  • MDRD Study
    • 585 nondiabetic patients with GFR 39 ml/min randomized to either 1.1 or 0.7 gm protein/kg/day
    • Results – Reduction of protein intake minimally ameliorated decline of GFR (1.1 cc/min/year)
protein restriction 0 6 gm kg and dm nephropathy
Protein Restriction (0.6 gm/kg) and DM Nephropathy

Zeller K et al, N Engl

J Med 324:78, 1991

Walker JD et al, Lancet 2:1411, 1989

ii managing complications of ckd anemia
II. Managing complications of CKDAnemia
  • Diagnosis of exclusion
  • Check iron stores
    • TSAT (iron/TIBC) 20-50%
    • Ferritin 100-600 ng/ml
  • Erythropoietin replacement therapy
  • Goal Hg 11-12 g/dL
slide30

II. Managing complications of CKDOsteodystrophy

  • High-turnover (osteitis fibrosa cystica) bone disease
  • Low-turnover (adynamic) bone disease
    • Resistance to PTH
    • Need for relatively higher PTH levels to maintain adequate bone remodeling
    • Low-turnover may have worse outcomes than high
  • Check phosphorous, calcium, intact PTH
slide32

II. Managing complications of CKDOsteodystrophy

  • Dietary phosphate restriction
  • Phosphate binders
    • Calcium carbonate, Calcium Acetate
    • Lanthanum Carbonate
    • Sevalamer
  • 1,25 Vitamin D
  • Calcimimetic- not approved for pre-ESRD
iii preparing for rrt vascular access
III. Preparing for RRTVascular access
  • Goal is to:
    • Increase use of fistulas
    • Avoid use of tunneled catheters
  • Save the Veins!
  • Avoid blood draws/IVs in non-dominant arm
  • NO subclavian central lines
iii preparing for rrt referral
III. Preparing for RRT Referral
  • > 50% of patients had 1st encounter with nephrologist within 1 year of RRT
  • 32% had 1st appt < 4 months before ESRD
  • Patients referred late (< 4 months before ESRD) had 72% greater mortality during the first year of HD compared with patients referred early (> 4 months before ESRD)

Stack AG, AJKD February 2003

chronic kidney disease summary
Chronic Kidney Disease summary
  • CKD- common final pathway
  • Stage using MDRD equation
  • Use spot urine protein:creatinine ratio
  • Goal is:
    • Prevention
    • Slow progression of disease
    • Prevent and manage complications
  • Control of proteinuria & blood pressure
    • RAAS inhibition
  • Early referral to nephrology