Prevalance of Chronic Kidney Prevalance of Chronic Kidney DiseaseDisease

26 million people have diagnosed chronic kidney 26 million people have diagnosed chronic kidney

disease (CKD) disease (CKD) ((National Kidney Foundation data 1/29/2009)National Kidney Foundation data 1/29/2009)

The awareness of Kidney DiseaseThe awareness of Kidney Disease

It is estimated that 10-20 million people unawareIt is estimated that 10-20 million people unaware they have CKD they have CKD (National Institute of Diabetes and Digestive Kidney Disease (National Institute of Diabetes and Digestive Kidney Disease data summer 2010 data summer 2010 ) )

Cause of this problem: Reliance Cause of this problem: Reliance

of many primary medical providers on the serumof many primary medical providers on the serum

creatinine alone. eGFR more accurate creatinine alone. eGFR more accurate

estimate.estimate.

Prevalance continuedPrevalance continued

eGFR is calculated by the MDRD equation eGFR is calculated by the MDRD equation

which uses age, weight , gender andwhich uses age, weight , gender and

serum creatinineserum creatinine Levey AS, Bosch JP, Lewis JB et all: (ann Intern Med 1999 130(6):461-470Levey AS, Bosch JP, Lewis JB et all: (ann Intern Med 1999 130(6):461-470

Example: 70 yoF with creatinine of 1.2 Example: 70 yoF with creatinine of 1.2

has GFR of 45ml/min; has GFR of 45ml/min;

a 20 yo M with same creatinine has GFR a 20 yo M with same creatinine has GFR

of >100ml/minof >100ml/min

Prevalance of CKD in Older Prevalance of CKD in Older PopulationPopulation

NHANES analysis 1999-2004 NHANES analysis 1999-2004

Those age 65 + have 44.7% CKDThose age 65 + have 44.7% CKD

Of these 54.6% have diabetesOf these 54.6% have diabetes

The 33.1% of non diabeticThe 33.1% of non diabetic

population has CKDpopulation has CKD

Of those in 74-80 age groupOf those in 74-80 age group

43.8% have CKD 43.8% have CKD ( 2008 USRDS Annual Data Report) ( 2008 USRDS Annual Data Report)

Functions of the kidneysFunctions of the kidneys

Red blood cell production via erythropoeitinRed blood cell production via erythropoeitin

Hypertension control through the renin Hypertension control through the renin

angiotension hormonal regulation of salt angiotension hormonal regulation of salt

balance and vasoconstrictionbalance and vasoconstriction

PTH regulation of calcium and phosphorusPTH regulation of calcium and phosphorus

metabolismmetabolism

Waste and fluid filtrationWaste and fluid filtration

Electrolyte balanceElectrolyte balance

StagesStages DescriptionDescription GFRGFR TreatmentTreatment

11 Kidney damage Kidney damage with normal GFRwith normal GFR oror

hyperfiltrationhyperfiltration

>90>90 Identify risk ofIdentify risk of

progressive progressive renal disease. renal disease. MonitorMonitor

regularly, treat regularly, treat HTN. HTN.

22 Kidney damage Kidney damage with with

mild decrease in mild decrease in GFRGFR

60-8960-89 Identify risk ofIdentify risk of

progressive progressive renal disease. renal disease. MonitorMonitor

regularly, treat regularly, treat HTN HTN

33 Moderate decrease Moderate decrease inin

GFR Proteinuria GFR Proteinuria HypertensionHypertension

30-6030-60 Refer if GFR Refer if GFR declines>25%/declines>25%/yrConsider yrConsider ACEI ARBACEI ARB

44 Severe decrease inSevere decrease in

GFRGFR 15-3015-30 PTH, calcium, PTH, calcium,

hgb and HTNhgb and HTN

55 Kidney failureKidney failure <15 (or <15 (or dialysis)dialysis)

Dialysis/or Dialysis/or transplanttransplant

Treatment Treatment by stagesby stages Stage 1 and 2 if proteinuria presentStage 1 and 2 if proteinuria present

Evaluate for risk of progressionEvaluate for risk of progressionManage hypertension if presentManage hypertension if present

Stage 3Stage 3 Use of angiotension converting Use of angiotension converting

enzyme inhibitors to control enzyme inhibitors to control hypertension and hypertension and proteinuria,proteinuria,

Identify and treat anemia and Identify and treat anemia and hyperparathyroidism, hyperparathyroidism,

Decrease medication doses as Decrease medication doses as appropriate, adjust insulin dose, appropriate, adjust insulin dose,

Educate on meal planning Educate on meal planning Appointments every 3-4 months with Appointments every 3-4 months with

lab testing lab testing Begin education regarding end stageBegin education regarding end stage

Stages continuedStages continued

Stage 4Stage 4 Same medical management as in stage 3Same medical management as in stage 3 Appointments every month with lab Appointments every month with lab

testing as GFR declinestesting as GFR declines Appointment to discuss end stage Appointment to discuss end stage

renal disease treatment options inrenal disease treatment options in detail with patient and family; access detail with patient and family; access

placement for dialysis; initiate placement for dialysis; initiate transplant workup if patient is transplant workup if patient is

a candidatea candidate Manage fluid status; need ongoing Manage fluid status; need ongoing

evaluationevaluation of edemaof edema Stage 5 Initiate dialysis or transplantStage 5 Initiate dialysis or transplant Close monitoring of weights, Close monitoring of weights,

evaluation of edema, evaluation of edema, and potassium,and potassium,

and phosphorus consumptionand phosphorus consumption

Treatment considerations by Treatment considerations by stage for insulin and oral agent stage for insulin and oral agent

useuseStageStage GFRGFR Insulin or oral agentInsulin or oral agent

1 & 21 & 2 Greater than Greater than 9090

Usual managementUsual management

33 60 – 9060 – 90 May have lower May have lower medication dose medication dose requirementrequirement

4 4 30-6030-60 Same as in stage 3Same as in stage 3

55 15-3015-30 May require higher May require higher medicationmedication

dose requirementdose requirement