ckd 1-5d gfr stages complications referral access/esrd
DESCRIPTION
CKD 1-5d GFR Stages Complications Referral Access/ESRD. Thomas Schumacher. GFR. Assessment of functional renal mass Plot course . Provides prognostic information Provides no information as to the cause Need imaging and UA for further information. Estimate of GFR. Inulin - PowerPoint PPT PresentationTRANSCRIPT
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CKD 1-5d GFR Stages
ComplicationsReferralAccess/ESRD
Thomas Schumacher
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GFRAssessment of functional renal mass
Plot course. Provides prognostic information
Provides no information as to the cause
Need imaging and UA for further information
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Estimate of GFRInulin
Scans Iohexol, Iothalamate, TcDTPA,
Creatinine Clearance Cockcroft Gault MDRD CKD EPI 24 hr. urine CrCL
Cystatin C
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Why not creatinine?At what level of creatinine does a 65 year-old
diabetic, hypertensive, white woman weighing 50 kg have CKD?
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Why not creatinine?At what level of creatinine does a 65 year-old
diabetic, hypertensive, white woman weighing 50 kg have CKD?
77% said Creatinine >1.5 mg/dl
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Why not creatinine?At what level of creatinine does a 65 year-old
diabetic, hypertensive, white woman weighing 50 kg have CKD?
77% said Creatinine >1.5 mg/dl
This equates to CrCl 30 mL/min, or GFR 37 mL/min/1.73m2
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Why not creatinine?At what level of creatinine does a 65 year-old
diabetic, hypertensive, white woman weighing 50 kg have CKD?
77% said Creatinine >1.5 mg/dl
This equates to CrCl 30 mL/min, or GFR 37 mL/min/1.73m2
A Cr of 1 = GFR of 59 mL/min/1.73m2
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Why not creatinineA 90 Kg male has a GFR of 120 ml/min goes
to a GFR of 70 ml/min. GFR x Scr = Constant. 120 x .9 = 108 70 x X = 108, therefore X( Scr) is 1.5 but in reality his creatinine only goes to 1.2
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Why not creatinine alone
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Pitfalls of Creatinine as a marker of GFRCompensatory Hyperfiltration and increased
tubular secretion as GFR decreases
Unrecognized Renal Disease
Steady State?
Age, Race and Body Type
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Variations in Serum CreatinineIncreased Serum Creatinine
decreased Serum Creatinine
DietRhabdomyolysisMedications Decrease secretion - Trimethoprim, Dronedarone, Cimetidine, Ranitidine, Famotidine, Tenofovir, Interfere with assay - Cefoxitin, Flucytosine
DKASupplements
Aging decreases production
DietDecrease muscle massDecreased GFR
increases creatinine secretion
Nephrotic SyndromeSickle Cell disease
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Classification of CKDNKF – Kidney Disease Outcome Quality
Initiative, (KDOQI ), in 2002
Modified by Kidney Disease Improvement Global Outcome ,(KDIGO).
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Definition of Chronic Kidney Disease Kidney damage for 3 months, with or without
decreased GFR
1) Pathological abnormalities
2) Biomarkers: abnormalities in composition of blood and/or urine (proteinuria/hematuria), or abnormalities in imaging tests (structural abnormalities).
GFR < 60mL/min/1.73m2 for >3 months
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The Purpose of staging To guide management of risk. Earlier identification allow therapeutic intervention sooner in
the course and thus initiate treatment effective in slowing or preventing progression to ESRD as well as the sequelae of CKD
1) Hematologic – GFR <30 2) Cardiovascular – GFR <60 3) Bone – GFR < 60 4) Metabolic – GFR < 30 5) Cognitive 6) HTN
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Chronic Kidney Disease Is Progressive
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Stages of CKD
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KDIEGOAlbumin to Creatinine Ratio 1) < 30 mg/g ,( 1-14, 15-29 mg/g)
2) 30-299 mg/g – High Albuminuria, ( microalbuinuria ) 3) >299 mg/g - Very High Albuminuria,
(Macroalbuminuria)
Stage 3a and 3b Cause
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Epidemic – CKD Affects 14% Of U.S. Population
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Incidence of ESRD in US 2005
AA - 991/million
American Indians - 516/million
Asians - 335/million
Caucasians - 268/million
USRD 2009
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USRDS 2012 ReportCKD Prevalence (%) in the NHANES
population
Overall increase from 12.3% to 14% from 1988-1994 to 2005-2010
Stage 3 CKD increased from 4.9% to 6.7%
http://www.usrds.org/atlas.aspx
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CKD Complications - Anemia
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Anemia starts early in CKD and worsens with disease progression
Kausz AT, et al. Dis Manage Health Outcomes. 2002;10(8):505-513.*Obrador GT, et al. J Am Soc Nephrol. 1999;10:1793-1800
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Complications of anemia LVH and other cardiac dysfunction Anemia at any GFR is more likely to be associated with LVH and HF Anemia, independent of GFR, in HF is associated with increased R.R for death Improvement in anemia in CKD was associated with improvement in NYHA functional class
Fatigue
Depression
Reduced exercise tolerance
Increased mortality
Silverburg DS Nephrol Dial Transplant 2003; 18(1):141
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Survival by Anemia and GFRARIC Study, 1986–2000
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Target HemoglobinChoir Trial – GFR 15-50, starting Hgb. <11.o. Goal
11.3 and 13.5
Create Trial- GFR 15-35 . Goal 13-15 or 10.5 -11.5
Treat Trial- Type II DM, GFR 20-60. Goal Hgb. 13
US Normal Hematocrit Trial- ESRD, Baseline 27 to 33. Goal 30 or 42 Hct.
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Cardiovascular disease mortality in the general population vs. ESRD
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CKD and Bone Mineral Disorders
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Vascular Calcification and CKD
EBCT Indicating Coronary Calcification
Medial Calcification Secondary to CKD
London GM, et al. Nephrol Dial Transplant. 2003:18(9):1731-1740
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CKD and Secondary Hyperparathyroidism in Stage 3-5 High rate of vascular calcification Treatment Dietary restriction
Phosphate bindersVitamin D analogues
Cincalcet No survival advantage demonstrated
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The Importance of Early Recognition
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Nephrology CKD Management
Hyperlipidemia
Smoking
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Who Should Be Referred (CKD)?Normal GFR but significant
proteinuria, hematuria, or structural abnormalities (solitary kidney, polycystic kidneys).
Stage 3-4 CKD.Rapid decline in GFR.Any doubt, better to refer early than
wait too long.
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The Importance of Early Referral135 patients at Tufts-New England Med Ctr.Adjusted for any differences in age, race, gender,
socioeconomic status, insurance coverage, comorbidities between LR and ER.
LR vs. ER Hypoalbuminemia: 80% vs. 56% Anemia: 55% vs. 33% Hct <28 GFR <5 ml/min/1.73m2 start of HD: 40% vs. 17% Receiving erythropoietin: 17% vs. 40% Functional fistula at start of dialysis: 4% vs. 40%
Arora et al. J Am Soc Nephrol 10:1281-1286, 1999.
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The Importance of Early Recognition40% of U.S. patients enter Stage 5 CKD (or
ESRD) less than 6 months after their initial referral to nephrology.
Missed Opportunities Possible reversible causes Benefits of renoprotection, delaying progression Benefits of cardioprotection Adequate preparation for kidney failure and treatments. Referral for transplantation
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The Importance of Early ReferralStark et al., AJKD 2003 Feb;41(2):310-8 2264 patients beginning hemodialysis Dialysis Morbidity and Mortality Study
Adjusted mortality risk: late referral (within 4 months of initiation of HD) RR 1.68 (as high as 2.94) compared to patients who saw a nephrologist a year before HD initiation.
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Types of Hemodialysis Access
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Types of Hemodialysis Access
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Types of Hemodialysis Access
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Preparation of Dialysis Functional AV fistula at the start of
hemodialysis: 4% of late referrals vs. 40% of early referrals.
2011 New York percentage of patients with AV fistula as primary HD access: 62%
KDOQI GOAL: >65%
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Pros and Cons – AV FistulaPros Optimal blood flow rates. Can last the longest. Lowest infection rate. Less likely to clot.
Cons Can take months to mature. Not all patients have adequate vessels. Needles involved. Cosmetics.
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Pros and Cons – AV GraftPros Can be placed in patients with inadequate vessels for an AV fistula. Need less time to “mature,” can be used within 2 to 3 weeks. Better blood flow than a catheter, and properly maintained can last well.
Cons Foreign material (graft) can be infected. More prone to clotting issues than fistula. Needles / cosmetic issues.
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Pros and Cons of CathetersPros Immediately ready to use. No needles.
Cons Low blood flows with more recirculation. Cause stenosis in veins, clot frequently. Infections. Infections. Infections
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The Problems With Catheters108 patients dialyzing via catheters. 48% had bacteremia by 6 months. Lee T, et al., AJKD 2005 Sep;46(3):501-8.
102 patients dialyzing via catheters 40% had bacteremia requiring catheter removal by 12 months Kieren A, et al., Annals of Int. Med. 1997 Aug; 127(4): 275-80.
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The Problems With Catheters66,595 Medicare patients aged 67 or older on
dialysis. One year crude death rates: AV fistula 24.9% Synthetic AV graft 28.1% Tunneled catheter 41.5% Xue JL, et al. AJKD 2003 Nov;42(5): 1013-9
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Fistula vs. CatheterCompared with arteriovenous fistulas, long term
dialysis with tunneled catheters is associated with:1. Two to threefold increased risk of death2. Five to tenfold increased risk of infection3. Increased rate of hospitalization4. Decreased adequacy of dialysis5. Increased number of vascular access
procedures Rehman R, et al. Clin J Am Soc Nephrol 4: 456-460, 2009.
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The Importance of Early Recognition
Brenner, et al. 2001
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Relation Between Time of Evaluation and Mortality Among All Patients from Cox Proportional Hazards Regression
Analysis
Adjusted for modality, demographic factors, SES factors, years smoking, exercise status, comorbidity (ICED), serum albumin, hematocrit, residual GFR. Kinchen KS et al. Annals of Internal Medicine 2002 ;137:479-86