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