CKDinform:APCP’sGuidetoCKDDetectionandDelayingProgression

LearningObjectives• Describesuitablescreeningtools,suchasGFRandACR,for

properutilizationinclinicalpracticerelatedtothediagnosisandmonitoringofCKD.

• DefineandclassifyCKD,basedonGFRandalbuminuriacategories,inordertoguideappropriatetreatmentapproaches.

• Recognizeevidence-basedmanagementstrategiesthatwillhelpdelayCKDprogressioninat-riskpatientsandimproveoutcomes.

CaseQuestion1A55year-oldCaucasian-Americanman,withahistoryoftype2diabetes(15years),hypertension(3years)dyslipidemia(5years)andcardiovasculardisease(myocardialinfarction3yearsago).HewasrecentlydiagnosedwithCKD.HismostrecentlabsrevealaneGFRof45ml/min/1.73m2 andanACRof38mg/g.Whichofthefollowingshouldbeavoided?

A.ACEandARBincombination

B.Dailylow-doseaspirin

C.NSAIDs

D.Statins

E.AandC

Allofthefollowingadultpatientsshouldbereferredfornephrologyconsultation,EXCEPT?

A.Initialvisit:eGFR26&3monthslater:eGFR28(mL/min/1.73m2)

B.Initialvisit:eGFR55,&3monthslater:eGFR43confirmedwithrepeateGFR45(mL/min/1.73m2)

C.Initialvisit:ACR450&3monthslater:ACR355(mg/g)onbothdatestheeGFR >60mL/min/1.73m2

D.Initialvisit:eGFR >60&3monthslater:eGFR >60(mL/min/1.73m2)withpersonalhistoryofAutosomalDominantPolycysticKidneyDisease

E.Initialvisit:eGFR42&3monthslater:eGFR44(mL/min/1.73m2)onbothdatestheACR<30mg/g

CaseQuestion2

StepstoCKDPatientCare1. DoesthepatienthaveCKD?2. AssessGFR,albuminuria.3. Determineetiology.4. Assessforevidenceofprogression.5. Assessforassociatedcomplications.6. Patienteducation.7. Assesslifeexpectancyandpatientwishesfor

dialysis/transplantation.

DefinitionofChronicKidneyDisease

• CKDisdefinedasabnormalitiesofkidneystructureorfunction,presentfor>3months,withimplicationsforhealth.

KidneyDisease:ImprovingGlobalOutcomes(KDIGO)CKDWorkGroup.KidneyIntSuppls.2013;3:1-150.

AssignAlbuminuriaCategory

AlbuminuriaCategoriesinCKD

Category ACR(mg/g) TermsA1 <30 NormaltomildlyincreasedA2 30-300 Moderatelyincreased*A3 >300 Severelyincreased**

*Relativetoyoungadultlevel.ACR30-300mg/gfor>3monthsindicatesCKD.**Includingnephroticsyndrome(albuminexcretionACR>2220mg/g).

KidneyDisease:ImprovingGlobalOutcomes(KDIGO)CKDWorkGroup.KidneyIntSuppls.2013;3:1-150.

AssignGFRCategoryGFRCategoriesinCKD

Category GFR Terms ClinicalPresentations

G1 ≥90 Normalorhigh Markersofkidneydamage(nephroticsyndrome,nephriticsyndrome,tubularsyndromes,urinarytractsymptoms,asymptomaticurinalysisabnormalities,asymptomaticradiologicabnormalities,hypertensionduetokidneydisease)

G2 60-89 Mildlydecreased*

G3a 45-59 Mildlytomoderatelydecreased

• Mildtoseverecomplications:o Anemiao Mineralandbonedisorder

§ Elevatedparathyroidhormoneo Cardiovasculardisease

§ Hypertension§ Lipidabnormalities

o Lowserumalbumin

G3b 30-44 Moderatelytoseverelydecreased

G4 15-29 Severelydecreased

G5 <15 Kidneyfailure • Includesalloftheabove• Uremia

GFR=mL/min/1.73m2

*RelativetoyoungadultlevelIntheabsenceofevidenceofkidneydamage,neitherGFRcategoryG1norG2fulfillthecriteriaforCKD.RefertoanephrologistandprepareforkidneyreplacementtherapywhenGFR<30mL/min/1.73m2.

KidneyDisease:ImprovingGlobalOutcomes(KDIGO)CKDWorkGroup.KidneyIntSuppls.2013;3:1-150.

ClassificationofCKDBasedonGFRandAlbuminuriaCategories:“HeatMap”

CKD is classified based on: • Cause (C) • GFR (G) • Albuminuria (A)

Albuminuria categories Description and range

A1 A2 A3

Normal to mildly

increased

Moderately increased

Severely increased

<30 mg/g <3 mg/mmol

30-299 mg/g 3-29

mg/mmol

≥300 mg/g ≥30

mg/mmol

GFR

cat

agpr

oes

(ml/m

in/1

.73

m2 )

Des

crip

tion

and

rang

e

G1 Normal or high ≥90 1 if CKD Monitor

1 Refer*

2

G2 Mildly decreased 60-89 1 if CKD Monitor

1 Refer*

2

G3a Mildly to moderately decreased

45-59 Monitor

1 Monitor

2 Refer

3

G3b Moderately to severely decreased

30-44 Monitor

2 Monitor

3 Refer

3

G4 Severely decreased 15-29

Refer* 3

Refer* 3

Refer 4+

G5 Kidney failure <15 Refer 4+

Refer 4+

Refer 4+

Colors: Represents the risk for progression, morbidity and mortality by color from best to worst. Green: low risk (if no other markers of kidney disease, no CKD); Yellow: moderately increased risk; Orange: high risk; Red, very high risk.

Numbers: Represent a recommendation for the number of times per year the patient should be monitored.Refer: Indicates that nephrology referral and services are recommended.

*Referring clinicians may wish to discuss with their nephrology service depending on local arrangements regarding monitoring or referral.

Adapted from Kidney Disease: Improving Global Outcomes (KDIGO) CKD Work Group. Kidney Int Suppls. 2013;3:1-150.

ScreeningTools:eGFR• Consideredthebestoverallindexofkidneyfunction.• Normal GFRvariesaccordingtoage,sex,andbodysize,and

declineswithage.• TheNKFrecommendsusingtheCKD-EPI Creatinine

Equation(2009)toestimateGFR.OtherusefulcalculatorsrelatedtokidneydiseaseincludeMDRDandCockcroft-Gault.

• ForGFRcalculatorssearch:GFRcalculator– TheNationalKidneyFoundation

SummaryoftheMDRDStudyandCKD-EPIEstimatingEquations:https://www.kidney.org/sites/default/files/docs/mdrd-study-and-ckd-epi-gfr-estimating-equations-summary-ta.pdf

eGFR,SCrComparison

Age Weight in lbsHeight in Ft/in

Sex Race SCr mg/dl

eGFR ml/minper CKD-EPI

eGFRAdj for BSA

25 2856’

M AA 1.6 68 97

49 1805’4’’

F Hispanic 1.6 38 41

67 1555’8’’

M Asian 1.6 44 46

92 985’1’’

F Caucasian 1.6 28 22

AverageMeasuredGFRbyAgeinPeopleWithoutCKD

CoreshJ,etal.AmJKidneyDis.2003;41(1):1-12.

UseTheseEquationsCautiously,ifatallin….• Patientswhohave/are:

o Poornutrition/lossofmusclemasso Amputationo Chronicillnesso NotAfricanAmericanorCaucasiano Changingserumcreatinineo Obeseo Veryelderly,young

ClinicalEvaluationofPatientswithCKD

• Bloodpressure• HbA1c• Serumcreatinine

o UseaGFRestimatingequationorclearancemeasurement;don’trelyonserumcreatinineconcentrationalone.

o Beattentivetochangesincreatinineovertime--evenin“normal” range.

• Urinalysiso Urinesedimento Spoturineforprotein-to-creatinineoralbumin-to-creatinineratio.

• Albuminuria/Proteinuria• Electrolytes,bloodglucose,CBC

• Dependingonstage:albumin,phosphate,calcium,iPTH• Renalimaging• DependingonageandH&P

o Lightchainassay,serumorurineproteinelectrophoresis(SPEP,UPEP)

o HIV,HCV,HBVtestso Complements,otherserologies—limitedroleunlessspecificreason

ClinicalEvaluationofPatientswithCKD

• Standardurinedipsticksdetecttotalprotein>30mg/dL-notsensitiveenoughfor“microalbuminuria” screening.

• Untimed,random“spot” urineforalbumin-to-creatinineorprotein-to-creatinineratio(firstmorningvoidpreferred).

ClinicalEvaluationofPatientswithCKD

• NormalAlbuminuriao Albumin-to-creatinineratio<30mg/gcreatinine

• ModeratelyIncreasedAlbuminuriao Albumin-to-creatinineratio30-300mg/gcreatinineo 24-hoururinealbumin30-300mg/d

• SeverelyIncreasedAlbuminuriao Albumin-to-creatinineratio>300mgalbumin/gcreatinineo 24-hoururinealbumin>300mg/d

• Proteinuriao (+)urinedipstickat>30mg/dlo >200mgprotein/gcreatinineo 24-hoururineprotein>300mg/d

Definitions:AlbuminuriaandProteinuria

SlowingProgressionofCKD

CKD- ProgressionofKidneyFailureConceptVariabledependingonseveralfactorsincluding(1)typeofdiseaseand(2)howwellitistreated

100

90

80

70

60

50

40

30

20

10

Years

Stage2

Stage3

Stage4

Stage5(Dialysis)

GFR

0 1 2 3 4 5 6 7

BloodPressureandCKDProgression

• ControlofBPmoreimportantthanexactlywhichagentsareused.o Avoidanceofside-effectsisimportant.

• Withproteinuria:diuretic +ACEior ARB.• Noproteinuria:nocleardrugpreference

o ACEior ARBoktouse.

Fujisaki K, et al. Impact of combined losartan/hydrochlorothiazide on proteinuria in patients with CKD and hypertension. Hypertens Res. 2014;37:993-998.

SlowingCKDProgression:ACEi/ARB• Checklabsafterinitiation.

o Iflessthan25%SCrincrease,continueandmonitor.o Ifmorethan25%SCrincrease,stopACEiandevaluateforRAS.

• Continueuntilcontraindicationarises,noabsoluteeGFR cutoff.• BetterproteinuriasuppressionwithlowNadietanddiuretics.• Avoidvolumedepletion.

GoalsforRenoprotection

• Targetbloodpressureinnon-dialysisCKD.1o ACR<30mg/g:≤140/90mmHg.o ACR30-300mg/g:≤130/80mmHg.*o ACR>300mg/g:≤130/80mmHg.o Individualizetargetsandagentsaccordingtoage,coexistentCVD,andothercomorbidities.

• AvoidACEiandARBincombination.3,4

o Riskofadverseevents(impairedkidneyfunction,hyperkalemia).

*Reasonabletoselectagoalof140/90mmHg,especiallyformoderatealbuminuria(ACR30-300mg/g).21) KidneyDisease:ImprovingGlobalOutcomes(KDIGO)BloodPressureWorkGroup.KidneyIntSuppl.

(2012);2:341-342.2) KDOQICommentaryonKDIGOBloodPressureGuidelines.AmJKidneyDis.2013;62:201-213.3) KunzR,etal. AnnInternMed.2008;148:30-48.4) MannJ,etal.ONTARGETstudy.Lancet.2008;372:547-553.

RelationshipBetweenAchievedBPandDeclineinKidneyFunctionfromPrimaryRenalEndpointTrials

UpdatefromKalaitzidisRandBakrisGLIn:HandbookofChronicKidneyDisease.DaugirdasJ(Ed.)2011.

NormaldeclineinGFR

Nondiabetes

MDRD.NEnglJMed.1993AIPRI.NEnglJMed.1996REIN.Lancet.1997AASK.JAMA.2002HouFF,etal.NEnglJMed.2006ParsaAet.al.NEJM2013

DiabetesCaptoprilTrial.NEnglJMed.1993HannadoucheT,etal.BMJ.1994BakrisG,etal.KidneyInt.1996BakrisG,etal.Hypertension.1997IDNT.NEJM.2001RENAAL.NEJM.2001ABCD.DiabetesCare(Suppl).2000

ARBsandProgressionofDiabeticNephropathy

Parving HH, et al. N Engl J Med. 2001

• Mostplacebo-controlledstudiesintype2DMhavebeeninpatientswitheithermoderatealbuminuria(A2)orestablishednephropathytreatedwithARB.

• ARBandACEiappeartobeequivalentformoderatealbuminuria(A2)andproteinuriareduction.

Managing Hyperglycemia• Hyperglycemiaisafundamentalcauseofvascularcomplications,

includingCKD.• Poorglycemiccontrolhasbeenassociatedwithalbuminuriain

type2diabetes.• Riskofhypoglycemiaincreasesaskidneyfunctionbecomes

impaired.• Decliningkidneyfunctionmaynecessitatechangestodiabetes

medicationsandrenallycleareddrugs.• TargetHbA1c~7.0%.

o Canbeextendedabove7.0%withcomorbiditiesorlimitedlifeexpectancy,andriskofhypoglycemia.

NKF KDOQI. Diabetes and CKD: 2012 Update.Am J Kidney Dis. 2012;60:850-856.

OtherGoalsofCKDManagement

• NSAIDavoidance• Limitsodiumintaketo<90mmol(2gmsodium;or5gmsodiumchlorideorsalt)perday.

• CVDmanagement:lipids,ASA(secondaryprevention),etc.

LipidDisordersinCKD

• Usestatinaloneorstatin+ezetimibeinadults>50yrswithCKD3-5(ND).

• Usestatinaloneinadults>50yrswithCKD1-2.• Inadults<50yrsusestatinaloneifhistoryofknownCAD,

MI,DM,stroke.• Treataccordingtoa“fireandforget” ratherthan“treatto

target” strategy.o TreatCKDpatients(Nondialysis)withstatinsorStatin/exterminate

combinationswithouttheneedforfollowupbloodtests.

KidneyDisease:ImprovingGlobalOutcomes(KDIGO)LipidWorkGroup.KidneyIntSuppl.2013;3:259-305.http://kdigo.org/home/2013/11/04/kdigo-announces-publication-of-guideline-on-lipid-management/

LipidDisordersinCKD

A 32% reduction in LDLà17% reduction in primary outcome (nonfatal MI, coronary death, nonhemorrhagic stroke, arterial revascularization).

No reduction in CKD progression, overall or CAD mortality, other individual CAD end-points.

BaigentC,etal.StudyofHeartandRenalProtection(SHARP).Lancet. 2011;11:60739-60743.

10-YearCoronaryRiskBasedonAgeandOtherPatientCharacteristics

CABG,coronaryarterybypassgrafting;CHD,coronaryheartdisease;CKD,chronickidneydisease;CVA,cerebrovascularaccident;DM,diabetesmellitus;MI,myocardialinfarction;PTCA,percutaneoustransluminalcoronaryangioplasty;TIA,transientischemicattack.

1)KidneyDisease:ImprovingGlobalOutcomes(KDIGO)LipidWorkGroup.KidneyIntSuppl.2013;3:259-305.2)HemmelgarnBR,etal. Overviewofthealbertakidneydiseasenetwork. BMCNephrol.2009:30:10.

Future10-yearcoronaryriskbasedonvariouspatientcharacteristics.Dataareunadjustedratesfrom1,268,029participantsintheAlbertaKidneyDiseasecohort.1,2

OverviewofManagingCKDComplications

ComplicationsofKidneyFailureStartinStage3andProgress

Kidney Failure

Malnutrition

Bone DiseaseBrittle bones and fractures

Anemia/blood lossDecrease production of red blood cells

Fluid OverloadWater Overload Acid Base Imbalance

Acidic BloodElectrolyte Abnormalities

HypertensionCardiac DiseaseVascular Disease

AnemiainCKD• InitiateirontherapyifTSAT≤30%andferritin≤500ng/mL(IViron

fordialysis,oralfornon-dialysisCKD).• IndividualizeESAtherapy– StartESAifHb<10g/dl,andmaintain

Hb<11.5g/dl.EnsureadequateFestores.o AppropriateironsupplementationisneededforESAtobe

effective.• ESAusuallynotrequiredfornephrogenicanemiauntillateCKD

4/CKD5.• Diagnosticworkupofanemiaisparticularlyimportantifseverity

ofanemiaisdisproportionatetoCKDstaging.• Importanttoavoidtransfusionintransplantcandidates.

o IftransfuseduseleukocytefiltertoreduceHLAsensitization.

CKD-MBDTesting

CKD Stage Calcium, Phosphorus

PTH25(OH)D

Stage 3 Every 6-12 months

Once then based on CKD

progressionOnce, then based on level and treatments

Stage 4 Every 3-6 months Every 6-12 months

Stage 5 Every 1-3 months Every 3-6 months

UseCKDprogression,presenceorabsenceofabnormalities,treatmentresponse,andsideeffectstoguidetestingfrequency.

CKD-MBD:ChronicKidneyDisease– MineralandBoneDisorder

CKD-MBD

• TreatwithD3asindicatedtoachievenormalserumlevels.• 2000IUD3po qdischeaperandbetterabsorbedthan

50,000IUofD2monthlydose.• Limitphosphorusindiet,withemphasisondecreasing

packagedproducts- RefertorenalRD.• Mayneedphosphatebinders.• DEXAdoesn’tpredictfractureriskinCKD3-5.

MetabolicAcidosis• OftenbecomesapparentatGFR<25-30ml/min/1.73m2.

• Moreseverewithhigherproteinintake.• Maycontributetobonedisease,proteincatabolism,andprogressionofCKD.• CorrectionofmetabolicacidosismayslowCKDprogressionandimprovepatients

functionalstatus.1,2

AdultswithCKD(eGFR15-30ml/min/1.73m2)withbicarbonate16-20mmol/L;treatedwithsodiumbicarbonatefor2yearstonormalizeserumbicarbonateconcentration.2

1) Mahajan,etal.KidneyInt.2010;78:303-309.2) deBrito-AshurstI,etal.JAmSocNephrol.

2009;20:2075-2084.

MetabolicAcidosis• Maintainserumbicarbonate> 22mmol/L.

o Startwith0.5-1mEq/kgperday.o Sodiumbicarbonatetablets:

• 325mg,625mgtablets;1g=12mEq.o Sodiumcitratesolution:

• 1mEq/ml.• Avoidifonaluminumphosphatebinders.

o Bakingsoda:• 54mmol/leveltsp.

Hyperkalemia• Firsttryreductionofdietarypotassium.• StopNSAIDs,COX-2inhibitors.• Stoppotassiumsparingdiuretics.

o Aldactone• Stoporreducebetablockers.• Avoidsaltsubstitutesthatcontain

potassium.• StoporreduceACEi/ARBs.

AcuteManagementofHyperkalemia

Treatment Expectedserum K+↓

Peakeffect Duration Mechanism

IV Calciumchloride

None Instant Transient Stabilizemyocardium

Insulin +dextrose 0.5-1mEq/L 30-60 mins 4-6hrs Cellularshift

B2-adrenergicagonists

0.5-1 mEq/L 30mins 2hrs Cellularshift

Sodiumbicarbonate

Variabledependingon

acidosis

4h Cellularshift

Loop/thiazidediuretics

Hours ↑renalK+excretion

KamelKS,WeiC.NephrolDialTransplant.2003;18:2215-2218.

ChronicManagementofHyperkalemia• Looporthiazidediuretics.• Laxatives:

o Aseffectiveascationexchangeresinsinsorbitol.o Thosethatinducesecretorydiarrheamaybemoreeffective(e.g.

bisacodyl).o DiphenoliclaxativesmaystimulatecolonicK+secretion.

• Cationexchangeresins:o Sodiumpolystyrenesulfonateo Mechanism:

• Theoretical:BoundNa+exchangedforK+incolonic/rectallumen.

• Likely:Accompanyingsorbitolinducesdiarrhea.o Usuallyrequiresmultipledoses.o Riskofbowelnecrosisorperforation.

RiskFactorsforInfectioninPeoplewithCKD• Advancedage

• Highburdenofcoexistingillnesses(e.g.,diabetes)

• Hypoalbuminuria

• Immunosuppressivetherapy

• Nephroticsyndrome

• Uremia

• Anemiaandmalnutrition

• Highprevalenceoffunctionaldisabilities

Kidney Disease: Improving Global Outcomes (KDIGO) CKD Work Group. Kidney Int Suppls. 2013;3:1-150.

VaccinationinCKD• AnnualinfluenzavaccineforalladultswithCKD,unless

contraindicated.

• PolyvalentpneumococcalvaccinewheneGFR <30ml/min/1.73m2

andathighriskofpneumococcalinfection(e.g.,nephroticsyndrome,diabetes,receivingimmunosuppression),unlesscontraindicated.Offerrevaccinationwithin5years.

• HepatitisBimmunizationwhenGFR<30ml/min/1.73m2.Confirmresponsewithappropriateserologicaltesting.

• Useofalivevaccineshouldconsiderthepatient’simmunestatus(e.g.,immunosuppression).

Kidney Disease: Improving Global Outcomes (KDIGO) CKD Work Group. Kidney Int Suppls. 2013;3:1-150.

MalnutritionandCKD• Malnutritionorproteinenergywasting(PEW)iscommonin

CKD,andisassociatedwithpoorpatientoutcomes.• MalnutritioninCKDbeginsasearlyasstages3and4.Risk

increaseswithprogressionofthedisease.• PreventingPEWormalnutritionmayrequireclinical

interventionstoassessnutritionalstatus,individualizestrategiesforpreventionandtreatment,providepatientinstruction,andpromotepatientadherence.

• Aspecialty-trainedregistereddietitiancanhelpaddressthenutritionalaspectssothatproteinwastingcanbediminished.

NKF KDOQI. Am J Kidney Dis. 2000;35(suppl 2):S1-S3.NKF KDOQI. Am J Kidney Dis. 2007;49(suppl 2):S1-S179.

ABalancedApproachtoNutritioninCKD:MacronutrientCompositionandMineralContent*

NKFKDOQI.AmJKidneyDis.2007;49(suppl2):S1-S179.

Adapted from DASH (dietary approaches to stop hypertension) diet.*Adjust so total calories from protein, fat, and carbohydrate are 100%. Emphasize such whole-food sources as fresh vegetables, whole grains, nuts, legumes, low-fat or nonfat dairy products, canola oil, olive oil, cold-water fish, and poultry.

*(CKDStages1-4)

EducationandCounseling• Ethical,psychological,andsocialcare(e.g.,socialbereavement,

depression,anxiety).• Dietarycounselingandeducationonotherlifestylemodifications

(e.g.,exercise,smokingcessation).• Involvethepatient,familyandchildrenifpossible.• Offerliteratureinbothtraditionalandinteractiveformats.• Useeducationalmaterialswritteninthepatient’slanguage.• Assesstheneedforlow-levelreadingmaterials.• Useinternetresourcesandsmartphoneappsasappropriate.• Usevisualaidssuchashandouts,drawings,CDs,andDVDs.• Involveotherhealthcareprofessionalsineducating

patients/families.• Beconsistentintheinformationprovided.

MentalHealthCounseling• Psychiatricillnesseslikedepressionareassociatedwithmany

chronicdiseases.• DepressionislinkedtoearlyCKD,progressiveCKD,kidney

failure,hospitalizationandincreasedmortality. 1-4

• PatientswithGFR<60mL/min/1.73m2shouldundergoregularassessmentforimpairmentoffunctioningandwell-being.5

1) PalmerS,etal. AmJKidneyDis.2013;62:493-505.2) HedayatiS,etal.AmJKidneyDis.2009;54(3):424-32.3) KimmelP,etal.KidneyInt.2000;57:2093-2098.4) TsaiY,etal.AmJKidneyDis.2012;60:54-61.5) NKFKDOQI.AmJKidneyDis.2002;39(2Suppl1):S1-266.

CKDCareAmongSpecialPopulations

ConsiderationsforCKDManagementinOlderAdults• Morethan36millionadultsarenowovertheageof65,and~50%have

twoormorechronicdiseases.1

• Managementrequiresanindividualizedapproach,withattentiontouniqueconsiderationsforolderadults.

• TreatmentofhypertensioninolderadultshasbeenshowntoreduceCVmorbidityandmortality.However,olderfrailadultsshouldbemonitoredforriskofhypotension.2,3

• Lessstringentglycemicgoalscanbeappropriateforolderadultswithothercomorbidities,orthoseathigherriskforhypoglycemia.4

• Exercisecanhavemultiplebenefits.Aweightcontrolprogramshouldbeindividuallytailoredtopreservebodycellmassandfunction,whilelosingfatmass.5,6

1. U.S.CensusBureau.Populationbyageandgender2008.www.census.gov.2. KatzP,GilbertJ.GeriatricsandAging.2008;11:509-514.3. AronowW.ClinGeriatrMed.2008;11(8):457-463.4. NKFKDOQI.AmJKidneyDis.201260:850-856.5. HornickT,AronD.ClevClinJMed.2008;75:70-78.6. NHLBI.ww.nhlbi.nih.gov.

IncidenceofESRDVariesWidelybyRaceandEthnicity

*Adjustedforageandsex;thestandardpopulationwastheU.S.populationin2011.Panelb:~Estimateshownisimpreciseduetosmallsamplesizeandmaybeunstableovertime.ThelineforNativeAmericanshasadiscontinuitybecauseofunreliabledataforthatyear.Abbreviations:AfAm,AfricanAmerican;ESRD,end-stagerenaldisease;NAm,NativeAmerican.USRDSADR2014.

(a)IncidentCases (b)IncidenceRates

Trends in (a) ESRD incident cases, in thousands, and (b) adjusted* ESRD incidence rate, per million/year, by race, in the U.S. population, 1980-2012.

Additional Online Resources for CKD Learning

• NationalKidneyFoundation:www.kidney.org

• UnitedStatesRenalDataService:www.usrds.org

• CDC’sCKDSurveillanceProject:http://nccd.cdc.gov/ckd

• NationalKidneyFoundation:www.kidney.org

• UnitedStatesRenalDataService:www.usrds.org

• NationalKidneyDiseaseEducationProgram(NKDEP):http://nkdep.nih.gov