chronic kidney disease hasan khamash md
TRANSCRIPT
Chronic Kidney Disease
Hasan Khamash MD
Assistant Professor of Medicine
KCOM
ESRD Rates Continue to Rise
USRDS, 2004
Prevalence of Renal Insufficiency in U.S.
Thus, about 8 million Americans have a GFR less than 60 mL/min/1.73 m2. Plus 11 million more have a GFR over 60 but have persistent microalbuminuria.
Coresh, et al., 2005
360,0007.7 MillionNumber of People
29-1559-30GFR
(mL/min/1.73 m2)
Incident Counts & Adjusted Rates, By Primary Diagnosis
USRDS, 2004
The Risk of Kidney Failure is Not Uniform
Relative risks compared to Whites:
African Americans 3.8 X
Native Americans 2.0 X
Asians/Pacific Islander 1.3 X
The relative risk of Hispanics compared tonon-Hispanics is about 1.5 X
USRDS, 2004
Kidney Failure Compared to Cancer Deaths in the U.S. in 2000
(in Thousands)
Seer, 2004
Lung Cancer KidneyFailure
ColorectalCancer
BreastCancer
Prostate Cancer
57
100
4130
160
CKD Predicts CVD
2.113.65
11.29
21.8
36.6
0
5
10
15
20
25
30
35
40
≥ 60 45-59 30-44 15-29 < 15
Go, et al., 2004
Ag
e-S
tan
da
rdiz
ed
Ra
te o
f C
ard
iova
scu
lar
Eve
nts
(p
er
10
0 p
ers
on
-yr)
Estimated GFR (mL/min/1.73 m2)
Costs of Kidney Failure are High(in $billions for 2002)
Kidney FailureCare Total NIH
Budget
25.223.2Kidney Failure Accounts for
6% of Medicare Payments
Lost Income for Patients is $2-4 Billion/Yr
USRDS, 2004
Prevalence of Renal Insufficiency in U.S.
Thus, about 8 million Americans have a GFR less than 60 mL/min/1.73 m2. Plus 11 million more have a GFR over 60 but have persistent microalbuminuria.
Coresh, et al., 2005
360,0007.7 MillionNumber of People
29-1559-30GFR
(mL/min/1.73 m2)
CKD is Not Being Recognized or Treated
• Most practices screen fewer than 20% of their Medicare patients with diabetes*
• Patients are referred late to a nephrologist, especially African-American men
• Less than 1/3 of people with identified CKD get an ACE Inhibitor
Kinchen, et al., 2002;McClellan et al.,1997
*Data provided by the USRDS based on 5 percent Medicare enrollment and claims data
Treatment to Prevent Progression of CKD to Kidney Failure
• Intensive glycemic control lessens progression from microalbuminuria in type 1 diabetes
- DCCT, 1993
• Antihypertensive therapy with ACE Inhibitors lessens proteinuria and progression- Giatras, et al., 1997- Psait, et al., 2000- Jafar, et al., 2001
• Low protein diets lessen progression- Fouque, et al., 1992- Pedrini, et al., 1996- Kasiske, et al., 1998
Meta-Analyses
Meta-Analyses
Plasme Creatinine and GFR
Other Measures
• Avoid nephrotoxic Meds.
• Address the possibility for bladder outlet problems.
• Volume over load Na restriction, Loop diuretic.
• Hyperkalemia K restriction, Loop diuretic if volume overloaded, Kayexalate.
Contrast Induced Nephropathy
• A small rise in the plasma creatinine concentration (averaging 0.2 mg/dL) is a common occurrence after a radiocontrast study.
• Risk Factors• Underlying renal insufficiency, Cr>1.5 mg/dL or
GFR<60 mL/min per 1.73 m2.• Diabetic nephropathy with renal insufficiency• Hypovolemia true or effective.• High total dose of contrast agent.• Multiple myeloma.
Recommendation
• Identify high risk patients esp. DM with GFR<60• Use other modalities if possible.• Avoid hypovolemia and NSAIDs.
• Low or iso-osmolal dye with least amount possible. Mix with gadolinium.
• NAC 600 mg BID day before and of test.• HCO3 drip.
• Possible role for high dose or IV NAC and hemofiltration esp for DM with Cr >4.
Early referral to nephrologist
• An informed selection of dialysis modality • Timely placement of appropriate dialysis access• Earlier initiation of dialysis
• Lower morbidity and improved rehabilitation • Slower progression of kidney failure
• Less frequent and shorter hospital stays • Lower cost • Improved survival
Causes for late referrals• Unaviodable cause: ARF, patient refusing
referral due to fear of dialysis.• Referral biases of physicians. Lack of training regarding timing or
indications.• Poor communications between physicians. Economic factors (fear of losing patients)• Structure of the health care system HMO
related.
