Download CKD Physician overview

Chronic Kidney
Disease (CKD)
Dr. Sham Sunder
Now we know
why the titanic sank !!
< 0.5 %
5- 10%
CKD – A scary
Challenge for Us all !!
CKD – Chronic kidney disease
We have intricate
things to learn !!
KIDNEY / DISEASE
OUTCOMES QUALITY
INITIATIVE
The K/DOQI
Practice Guidelines of CKD
The National Kidney Foundation (NKF)
National Kidney Diseases Education Program
The NKDEP
Physicians Must be Engaged
Indian scenario
1.
80 lak pts with eGFR 30-60 ml/min/1.73 m2
2.
Pts with albuminuria are double this number
3.
About 2,000 full-time nephrologists
4.
Nearly 4,000 new patients per nephrologist
5.
Means 11 new pts per day per nephrologist
6.
Obviously not possible. Physicians must treat CKD
CKD – A Silent Killer
CKD – Increased Death
CKD at a glance
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CKD – A Global Pandemic
CKD 1-2 are asymptomatic
Third after CVD, Cancer
1 in 10 Indians have CKD
10 million people of CKD
Term ‘CRF’ no longer used
Dialysis ↑ death rate 100 x
Small ↑ in Creat - ↑ ↑ in CV
The Nephron
Filtration, Reabsorption and Secretion
Normal GFR 120 ml/min/1.73m2
Only 20% nephrons work at a time
In a day 210 L of water is filtered
2 L /day of urine is excreted
Definition of CKD
1.
Either GFR < 60 ml/min/1.73m2 for  3 mon or
2.
Kidney damage for  3 mon as manifested by
a.
Persistent microalbuminuria / macroproteinuria
b.
Biochemical abnormalities in RFT
c.
Persistent non-urological hematuria
d.
Structural renal abnormalities by USG
e.
Biopsy proven Glomerulonephritis (rarely needed)
(Any one of the above evidences)
CKD Clinical Stages
Stage Description
GFR
(ml/min/1.73 m2)
1
Kidney damage with normal or ↑ GFR
 90
2
Kidney damage with mild  GFR
60-89
3
Kidney damage with moderate  GFR
30-59
4
Severe  GFR
15-29
5
Kidney Failure (ESRD)
< 15 (or dialysis)
ESRD versus Total CKD
K/DOQI CKD Staging
Natural History of Nephropathy
Definition of ESRD vs Kidney Failure
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ESRD is a federal government defined term that
indicates chronic treatment by dialysis or
transplantation
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Kidney Failure: GFR < 15 ml/min/1.73 m2 or
on dialysis
Global profile of ESRD
Prevalence of Abnormalities
at each level of GFR
Proportion of population (%)
Hypertension*
Unable to walk 1/4 mile
Serum calcium < 8.5 mg/dL
Hemoglobin < 12.0 g/dL
Serum albumin < 3.5 g/dL
Serum phosphorus > 4.5 mg/dL
90
80
70
60
50
40
30
20
10
0
15-29
30-59
60-89
90+
Estimated GFR (ml/min/1.73 m2)
*>140/90 or antihypertensive medication
p-trend < 0.001 for each abnormality
CKD Features – Stage wise
CKD
eGFR
B.P
ACR
Urine
Edema
Anemia
Ca x P
SHPT
Stage 1
>90
N
MAU
N
No
No
N
No
Stage 2
60+
↑
MAU
↑
No

N
No
Stage 3
30 +
↑
ALB
↑
No

N

Stage 4
15+
↑
ALB
↑↓


↑
↑
Stage 5
<15
↑↑
ALB
↓


↑
↑
Death rates from all causes (panel A) and
cardiovascular events (panel B), as per eGFR
Go, A, et al. NEJM 351: 1296
Physicians and Nephrologist in
CKD
How to handle CKD ?
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A
B
C
D
A1c < 6.5, ACEi, ARBs
Blood pressure < 125/75
Cholesterol LDL < 100
Drugs – avoid nephrotoxicity
Diet – Moderate in protein
Na, K, Ph, Fluids, Cal
CKD – Management Strategy
1.
Decrease Cardiovascular Risk
2.
Arrest or slow progression to ESRD
3.
Manage complications –
1.
Anemia (Normocytic normochromic)
2.
Bone loss (Renal osteodystrophy)
CKD – Management Goals
1.
Blood pressure < 125/75
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2.
3.
4.
HT is both a cause and consequence
Glycemic control – Hb A1c < 6.5
Hemoglobin level > 11 g%
Calcium x Phosphorous product < 50
Normal values :
GFR 120 to 150 ml/min/1.73m2
Ca 9 to10.5mg%, Ph 3 to 4.5mg%, Ca x Ph < 50
iPTH 150 to 300 pg/ml
Early treatment makes
a difference in CKD
Brenner, et al., 2001
Stages in Progression of Chronic Kidney
Disease and Therapeutic Strategies
Complications
Normal
Screening
for CKD
risk factors
Increased
risk
CKD risk
reduction;
Screening for
CKD
Damage
Diagnosis
& treatment;
Rx. comorbid
conditions;
↓ progression
 GFR
Kidney
failure
Estimate
Replacement
progression;
by dialysis
Rx. complications; & transplant
Prepare for
replacement
CKD
death
Stage-wise management of CKD
Stage 0
Test for CKD, Management of Risk Factors
Stage 1
Manage co-morbidity, Rx. of CVD and RF
Stage 2
Slow rate of loss of Kidney function - ACEi
Stage 3
Prevent Anemia, Bone effects, Ca x Ph
Stage 4
Preparation for RRT; refer to nephrology
Stage 5
RRT – PD, HD or RT – Donor / Cadavre
Preparation for RRT
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Choice of Renal Replacement
Timely Access Surgery
Timely Dialysis initiation
When GFR < 25ml/min
 Renal transplant is the first choice
 Workup living donors
 If no donors available
 List patient on cadavre transplant list
 Place A-V fistula if HD preferred
Conclusions
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CKD – ESRD patient population is increasing
in our country
Early detection and proper management has
many advantages
Later stages, i.e. ESRD – RRT is required
Various modalities of RRT – Dialysis (Hemo/
Peritoneal) as well as renal transplantation
available
Let this not happen please!
Normal
ESRD