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Overview of Chronic Kidney Disease and ESRD

Overview of Chronic Kidney Disease and ESRD. Gordon McLennan, MD. 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. Take Home Message.

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Overview of Chronic Kidney Disease and ESRD

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  1. Overview of Chronic Kidney Disease and ESRD Gordon McLennan, MD

  2. 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

  3. 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

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

  5. Chronic Kidney Disease • Glomerular filtration rate (GFR) <60mL/min/1.73m2 for >3 months with or without kidney damage OR • Kidney damage for >3 months, with or without decreased GFR, manifested by either • Pathologic abnormalities • Markers of kidney damage, eg, proteinuria • Affects 11% of US popluation

  6. CKD Stages 0-4 NHANES III 1988-1994 Stage 5 USRDS 1998

  7. 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 32:S112-S119, 1998 (suppl 3)

  8. Incidence of End Stage Renal Disease (ESRD) According to Primary Diagnosis USRDS. 2004. Available at:http://www.usrds.org/atlas.htm.

  9. 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 339:799-805, 1998

  10. Life Expectancy Patients Diagnosed with CKD ± DM Have a Greater Likelihood of Death than ESRD First nephrologist visit at an outpatient clinic (n=20,363) 100 80 60 40 20 0 n=11,698 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 21.60 20.42 8.27 NDM/Non-CKD DM/Non-CKD NDM/CKD DM/CKD Status in the entry period

  11. 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 physician’s care, so targeted screening of at-risk populations is cost-effective • For those patients under a physician’s 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 <60 ml/min/1.73m2) to provide strategic guidance is associated with improved outcomes

  12. 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

  13. 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: 2573–2580, 2003

  14. 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?

  15. MRA • Hydrate overnight • Bicarb • N-Acetyl Cystine • Use alternative contrast agents • Nothing special—Do arteriogram & limit contrast as much as possible

  16. 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

  17. 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)

  18. Early Detection of CRF Interventions that delay progression Prevention of uremic complications Modification of comorbidity Preparation for RRT ACE inhibitors Malnutrition Cardiac disease Education BP control Anemia Vascular disease Informed choice of RRT Osteodystrophy Blood sugar control Neuropathy (in diabetics) Timely access placement Acidosis Protein restriction Retinopathy (in diabetics) Timely initiation of dialysis Optimal CKD Patient Care

  19. Assessment for Renal Replacement Therapy • Transplant • Peritoneal Dialysis • Hemodialysis • AVF • Graft • Synthetic Material • Biological Material (Bovine Carotid Artery) • Catheter

  20. 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.

  21. Incident Patients

  22. Prevalent Patients

  23. NVAII Goals • By June 2006 • 40% prevalent fistulas • 50% incident fistulas • By June 2009 • 66% prevalent fistulas

  24. Routine CQI review of vascular access Early referral to nephrologist Early referral to surgeon for “AVF only” Surgeon selection Full range of appropriate surgical approaches AVF placement in catheter patients Cannulation training Monitoring and surveillance Continuing education: staff and patient Secondary AVFs in AVG patients Outcomes feedback NVAII Change Concepts

  25. 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 Algorithms

  26. AVF Types

  27. 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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