chronic kidney disease guide

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GLICKMAN UROLOGICAL & KIDNEY INSTITUTE SAME-DAY APPOINTMENTS 216.444.6771

Chronic KidneyDisease

Treatment Guide

Why choose Cleveland Clinic for CKD care?

Kidney specialists (nephrologists) in Cleveland Clinics Department o

Nephrology & Hypertension are experts in the evaluation and mana

ment of CKD. The nephrology program is ranked No. 2 in the natio

by U.S. News & World Report.Their CKD Clinic uses an innovative

team approach, in which the nephrologists are supported by nurse

practitioners, physician assistants, nutritionists and educators. The

team focuses on educating and involving patients in the daily man-

agement of their disease and in decisions about dialysis and kidney

transplant options. The goal is to manage the disease so that patien

can enjoy a better quality of life.

Cleveland Clinics electronic medical record is critically important fo

monitoring chronic disease status over time and interacting with a

number of different Cleveland Clinic specialists, like cardiologists an

endocrinologists, involved in the total care of the patient.

Despite best ef forts, kidney function can decline to a level that requ

more than medical and dietary intervention. When kidney transplan

tion becomes an option, patients can feel comfortable knowing that

Cleveland Clinic has one of the most experienced kidney transplant

programs in the world. When dialysis is needed, several state-of-the

forms are offered, including overnight dialysis at home.

Your Guide to

Chronic Kidney Disease

A number of diseases, including diabetes and

high blood pressure, can prevent your kidneys

from functioning at their best. When kidney

function steadily worsenschronic kidneydisease, or CKDwaste builds up in the blood.

You can become anemic and develop weak and

brittle bones. CKD also increases the risk of

stroke and atrial brillation. CKD is managed as

long as possible with medications and a special

diet. As the disease progresses, however, you

may require a kidney transplant or dialysis.

Early detection and appropriate treatment are

important in slowing the disease process, with

the goal of preventing or delaying kidney failure.

Cleveland Clinic kidney specialists offer a

comprehensive program for patients with all

stages of CKD. This guide provides an overview

of treatment options for CKD offered at Cleve-

land Clinic, as well as information you need to

become an active participant in your care.


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It is important to diagnose declining kid-

ney function in its earliest stages, whentreatment is most effective at delaying

the downward spiral to kidney failure.

Cleveland Clinic nephrologists encourage

all adults to have a routine urinalysis as a

part of their yearly health evaluation. It is

particularly important if you have a family

history of CKD, diabetes, unsuccessfully

treated hypertension, an illness that could

affect the kidneys, or take prescription or

over-the-counter non-steroidal anti-inam-

matory drugs, as these factors increase the

risk for developing kidney disease. It is also

important to have your kidney function test-

ed if you are planning to undergo coronary

artery bypass surgery, since surgery can

make abnormal kidney function worse.

CLEVELAND CLINIC | CHRONIC KIDNEY DISEASE | TREATMENT GUIDE

What is CKD?Over time, diabetes, high blood pressure and other diseases, in-

cluding autoimmune and congenital diseases, can damage the

kidneys. Depending on the disease and the part of the kidney

it affects, you may be diagnosed with a form of kidney disease

such as diabetic nephropathy, polycystic kidney disease, glo-

merulonephritis or hypertensive nephrosclerosis. The term CKD

applies to all. It indicates that the kidneys ability to lter waste

and water from your blood has weakened, is irreversible and

has dropped to less than 60 percent of normal function.

If you have CKD, you may notice you feel tired and have less

energy, urinate more often, have trouble concentrating or sleep-

ing, have little appetite, muscle cramps at night, swollen feet

and ankles, puffy eyes, and skin that feels dry and itchy.

How CKD is diagnosed

Two blood tests are performed to diagnose CKD:

Glomeruloltration rate (GFR), to determine how well your

kidneys are ltering blood.

Serum creatinine, to understand how well your kidneys

are removing waste products.

The results of these tests are considered along with your age,

race, gender and other factors to determine your kidney func-

tion. There are ve stages of CKD:

Stage 1= GFR 130-90: Normal to elevated kidney function

Stage 2= GFR 90-60: Kidney damage with mildly

decreased kidney function

Stage 3= GFR 60-30: Moderately decreased kidney function

Stage 4= GFR 30-15: Poor kidney function

Stage 5= GFR less than 15: Kidney failure

What your kidneys do

Your kidneys play many vital roles in your

health. Their primary function is to lter your

blood to remove waste and water. Healthy

kidneys lter about 200 quarts of blood every

day and produce about two quarts of urine.

Your kidneys also:

Balance your bodys salt, potassium

and acid levels

Produce hormones that regulate your

blood pressure

Control calcium metabolism and the

production of red blood cells

Produce the type of vitamin D you need

to build strong bones.

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TREATMENT GUIDE| CHRONIC KIDNEY DISEASE | CLEVELAND CLINIC


GLICKMAN UROLOGICAL & KIDNEY INSTITUTE

The CKD Clinic

Patients with a GFR of less than 45 may benet

from visiting one of our CKD Clinics. Cleveland

Clinic CKD Clinics are held at mulitiple locations,including the main campus.

At the CKD Clinic, you will undergo thorough kid-

ney function testing ,and a comprehensive cardio-

vascular risk assessment that includes innovative

approaches to blood pressure measurement (BP

Tru, central BP assessment) and a cholesterol test.

The results will determine the stage of your kidney

disease and extent of your cardiovascular risk. The

nephrologist will use this information to make anindividualized treatment plan.

At subsequent visits, a registered dietitian will

provide you with nutritional and dietary interven-

tions for CKD, as well as for cardiovascular disease

and/or diabetes, if needed. A nurse practitioner will

follow your progress. If you are likely to need future

dialysis, you will be assessed on a regular basis.

It is important that you become an active part of

your treatment team. The goal is to help you gainan understanding of the risks of kidney failure,

the goals of management and the benets of your

treatment options. It is hard work that requires you

keep your medical appointments, take your medi-

cations as prescribed, stick to your diet and pay

close attention to your blood pressure and blood

sugar. By working closely with the CKD team, you

may be able to delay the need for transplantation

or dialysis.

We encourage you to bring a family member or

friend with you to your appointments. Bringing a

patient advocate with you may help you ask the

right questions to get the information you need to

be a partner in your disease management.

Improving CKD care and outcomes

Cleveland Clinic nephrologist Joseph Nally Jr., MD, has

been awarded a three-year, $720,000 grant from the

National Institute of Diabetes and Digestive and Kidney

Diseases (NIDDK) to study and develop approaches

for disease management for patients with chronic

kidney disease.

The grant will fund clinical trials to test two approaches

to improving CKD care and outcomes. The rst trial will

adapt a patient navigator model, where patients are paired

with a non-clinical professional who is trained to identify

issues and barriers during the care process, such as insur-

ance, transportation to appointments and communication

with caregivers. The second trial will test enhancements to

the electronic health record designed to assist health careproviders in identifying and following patients who show

signs of deteriorating kidney function.

For information about this study, please

call research coordinator Barbara Tucky

at 216.444.1044.


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Medical therapy

Most patients with CKD are given an angiotensin-converting en-

zyme (ACE) inhibitor or an angiotensin receptor blocker (ARB)

to lower the blood pressure in their kidneys. You may also needa diuretic to help your body eliminate extra uid.

If you have glomerulonephritis, you may be given steroids and

an immunosuppressant medication such as cyclosporine.

Certain patients with CKD require other medications. These

may include:

a phosphate binder, if your kidneys are unable to

eliminate phosphate

vitamin D and calcitrol to prevent bone loss

erythropoetin to build red blood cells, if you are anemic.

Dietary guidelines

Following a CKD diet is as important as taking medications in

maintaining your kidney function. Cleveland Clinic dietitians are

experts in balancing the dietary needs of patients with CKD to

support kidney function while minimizing the impact of diabe-

tes, high blood pressure or cardiovascular disease.

A CKD diet limits sodium to prevent swelling and high blood

pressure, and in certain patients, restricts protein intake to pre-

vent elevated urea in the blood. It also balances calcium and

phosphorus to prevent bone loss and helps maintain proper po-

tassium levels to prevent a potentially fatal arrhythmia. Because

there are many foods you will not be able to eat, nutritional

supplements may be added to ensure you get enough calories.

If you have diabetes, your primary source of calories will be-

come simple carbohydrates. If appropriate the option of earlykidney/pancreas transplantation will be discussed.

A CKD diet is not always easy to follow. If you stick to the diet

faithfully, keep your blood sugar and blood pressure under con-

trol, and take your medications as instructed, you should feel

better, retain less uid and be less itchy. You will also be less

likely to lose bone density.

TreatmentOptionsTreatment is designed to delay the pro-

gression of the disease to kidney failure.

Most patients benet from the combina-

tion of medications and dietary changes.

If your kidney function drops below a

glomerular ltration rate (GFR) of 20, you

will be evaluated for a kidney transplant.

If you are not considered a candidate for

transplantation, dialysis will be started

once your kidney function reaches 10,

or possibly earlier.


CLEVELAND CLINIC | CHRONIC KIDNEY DISEASE | TREATMENT GUIDEGLICKMAN UROLOGICAL & KIDNEY INSTITUTE


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Kidney transplantation

If your kidney function drops to a GFR less than 20, you will

be evaluated for a kidney transplant, even before you actually

need to start dialysis. A new, healthy kidney can improve your

strength, stamina and energy. After transplantation, you should

be able to return to a more normal lifestyle. You will be allowed

to eat a normal diet and drink uids normally. Any anemia may

resolve, and if you have high blood pressure, you might need

fewer blood pressure medications. Because kidney transplan-

tation is so benecial, Cleveland Clinic nephrologists prefer to

transplant patients kidneys before they need dialysis.

If you have diabetic nephropathy, you may be able to receive

a new pancreas along with a kidney, eliminating the need for

insulin or other diabetes medication.

Donor WIn

Cleveland Clinics Transplant Center offers a

unique program of wellness assessment and

maintenance designed to ensure the continuedgood health of our kidney donor patients. Called

the Donor Wellness Initiative, or Donor WIn,

the program consists of:

A detailed physical examination

Sophisticated measurement of

cardiovascular health

Dietary and tness evaluations

Evaluation of kidney function

For more information about DonorWIn,

visit ccf.org/donorwin.

Dialysis

When kidney function drops dramatically, dialysis

is required to purge the body of waste and uid.

Several different types of dialysis are available,

with the most common forms being hemodi-

alysis and peritoneal dialysis. In hemodialysis,

the blood is circulated through a machine that

extracts uid and waste before returning the

cleansed blood to the body. Hemodialysis

generally requires patients to spend several

hours several times a week at a dialysis center.

In peritoneal dialysis, a solution is run directly

into the abdomen, where it absorbs waste

products. The waste products are then ltered

out naturally by the abdominal membrane

(peritoneum), and the solution drained out of the

body at scheduled intervals. Based on clinical

trials suggesting that slow dialysis may be better,

Cleveland Clinic nephrologists provide arrange-

ments for some patients to have overnight

hemodialysis and peritoneal dialysis at home.

TREATMENT GUIDE| CHRONIC KIDNEY DISEASE | CLEVELAND CLINIC GLICKMAN UROLOGICAL & KIDNEY INSTITUTE

Patient Evaluations for Kidney Transplant

Now Available at South Pointe Hospital

Physicians from Glickman Urological & Kidney Institute

ranked urology and nephrology programs are now available

in the Medical Ofce Building at South Pointe Hospital to see

kidney disease patients interested in transplantation. Potential

transplant candidates include patients suf fering from chronic

kidney disease (CKD) Stage 4 or 5, or patients currently

receiving chronic dialysis treatment.

For more information, please call 216.444.6996.
http://my.clevelandclinic.org/urology-kidney/departments-centers/urology/center-renal-transplantation.aspxhttp://my.clevelandclinic.org/urology-kidney/departments-centers/urology/center-renal-transplantation.aspx


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Looking aheadThere is no cure for CKD, and there are many questions about

the disease that remain unanswered. For example, although it

is known that high blood pressure, high blood lipid levels, high

phosphorus levels and uncontrolled diabetes are accelerate kid-

ney function decline, no one knows whether correcting these

issues affects the rate of CKD progression.

Cleveland Clinic physicians are dedicated to nding answers

to these and other issues affecting patients with CKD through

clinical studies. A key aid in this effort is the CKD Registry,

made possible by data gathered through Cleveland Clinics elec-

tronic health records system. The CKD Registry now contains

demographic and treatment information on more than 70,000

patients with CKD treated at Cleveland Clinic. The information

is vitally important in helping pinpoint which factors cause

CKD and regulate its progression, which tests are most useful

in diagnosing the disease and monitoring it progression, and

which medications are most effective at decreasing complica-

tions and retarding the deterioration of kidney function. To date,

Cleveland Clinic physicians have used the information in theCKD Registry to identify markers of all-cause and CKD-related

mortality and to verify the accuracy of new diagnostic test for

CKD. In keeping with the Cleveland Clinics policy on sharing

advancements in medicine, a paper detailing how to develop

and use a CKD registry has been published.

Cleveland Clinic nephrologists also conduct clinical trials (re-

search) of promising medications and procedures for patients

with CKD. Projects currently underway include an investigation

of the role of stem cells in protecting the kidney during coronary

artery bypass surgery, an examination of alternative biomarkers

to creatinine for predicting early kidney damage, and a clinical

trial of a medication that may decrease the need for dialysis in

patients with diabetes. Near term studies will examine the role

of kidney nerve denervation for controlling blood pressure in

patients with CKD.

CKD in children

At Cleveland Clinic Childrens Hospital,

children with CKD receive the same out-

standing treatment from the full range of

medical professionals with expertise and

experience treating the disease in pediat-

ric patients, including:

Pediatric nephrologists

Pediatric physician assistants

Pediatric nurse clinicians

Pediatric renal (kidney) dietitians

Family educators.

For the most part, CKD care is similar in

children and adults. Initially, the disease

and its underlying causes or complica-

tions, such as hypertension or diabetes,

are managed as long as possible with

medications and diet before kidney trans-

plantation or dialysis become options.

A key factor of CKD in children, however,

is managing delayed growth. Cleveland

Clinic pediatric nephrologists offer growth

hormone therapy and other treatments for

growth failure as part of CKD care.


CLEVELAND CLINIC | CHRONIC KIDNEY DISEASE | TREATMENT GUIDEGLICKMAN UROLOGICAL & KIDNEY INSTITUTE


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TREATMENT GUIDE| CHRONIC KIDNEY DISEASE | CLEVELAND CLINIC GLICKMAN UROLOGICAL & KIDNEY INSTITUTE

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Health Center

Chronic Kidney

Disease Specialists

Director: Joseph V. Nally, Jr., MD

Nurse Practitioner: Jennifer Hyland, CNP

Physicians:

Sevag Demirjian, MD

Richard Fatica, MD

Michael Ganz, MD

Phillip Hall, MD

Robert J. Heyka, MD

Priya Kalahasti, MD

Sheru Kansal, MD

Michael Lioudis, MD

Joseph V. Nally, Jr., MD

Sankar Navaneethan, MD

Saul Nurko, MD

Emilio Poggio, MD

Marc A. Pohl, MD

Martin Schreiber, Jr., MD

James F. Simon, MD

Brian Stephany, MD

Jonathan Taliercio, MD

George Thomas, MD

To learn more about these physicians,

please visit ccf.org/staff.

To make an appointment at one

of our CKD Clinics, please contact

our appointment scheduling

office at 216.444.6771.

Same day appointments available.

Nephrology Locations

13-URL-1326

chronic kidney disease guide

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