Overview of Chronic Kidney Overview of Chronic Kidney Disease and ESRDDisease and ESRD

Gordon McLennan, MDGordon McLennan, MD

Conflicts & AcknowledgmentsConflicts & Acknowledgments

Member, Board of Trustees, The Renal Member, Board of Trustees, The Renal Network Inc.Network Inc.Grant SupportGrant Support– Boston Scientific CorporationBoston Scientific Corporation– Omnisonics Medical TechnologiesOmnisonics Medical Technologies– Cook, Inc.Cook, Inc.– W. L. Gore, Inc.W. L. Gore, Inc.– Arrow InternationalArrow International

Take Home MessageTake Home Message

CKD represents a much larger problem CKD represents a much larger problem than ESRDthan ESRDUse of calculated GFR to assess renal Use of calculated GFR to assess renal function will help us identify patients at risk function will help us identify patients at risk for ESRDfor ESRDIt is incumbent on us to identify patients It is incumbent on us to identify patients who can have fistulas placed at stage 3 & who can have fistulas placed at stage 3 & 4 CKD4 CKD

Chronic Kidney Disease & ESRDChronic Kidney Disease & ESRD

ESRD (Renal ESRD (Renal Failure affects Failure affects only about only about 400,000 400,000 AmericansAmericansChronic Kidney Chronic Kidney Disease affects Disease affects 8 Million8 Million

Chronic Kidney DiseaseChronic Kidney DiseaseGlomerular filtration rate (GFR) <60mL/min/1.73mGlomerular filtration rate (GFR) <60mL/min/1.73m22 for for >>3 months with or 3 months with or without kidney damagewithout kidney damage

OROR

Kidney damage for Kidney damage for >>3 months, with or without decreased GFR, manifested by 3 months, with or without decreased GFR, manifested by eithereither– Pathologic abnormalitiesPathologic abnormalities– Markers of kidney damage, eg, proteinuriaMarkers of kidney damage, eg, proteinuria

Affects 11% of US popluation Affects 11% of US popluation

CKDCKD

Stages 0-4 NHANES III 1988-1994Stages 0-4 NHANES III 1988-1994Stage 5 USRDS 1998Stage 5 USRDS 1998

StageStage DescriptionDescription GFRGFR PrevalencePrevalence

mL/min/1.73 mL/min/1.73 mm22

N (1000’s)N (1000’s) %%

00 At increase risk of At increase risk of CKDCKD

>> 90 90 20,00020,000 11.211.2

11 Kidney damage w/ Kidney damage w/ normal or normal or ↑ GFR↑ GFR

>> 90 90 5,9005,900 3.33.3

22 Kidney damage w/ Kidney damage w/ mild mild ↓ GFR↓ GFR

60-8960-89 5,3005,300 3.03.0

33 moderate moderate ↓ GFR↓ GFR 30-5930-59 7,6007,600 4.34.3

44 severe severe ↓ GFR↓ GFR 15-2915-29 400400 0.20.2

55 Kidney FailureKidney Failure <15 or <15 or dialysisdialysis

300300 0.10.1

Co-morbidities of CKDCo-morbidities of CKD

50-500 x 50-500 x mortalitymortalityPredominant Predominant cause is cause is CVDCVD

Foley RN, Parfrey PS, Sarnak MJ: Clinical epidemiology of cardiovascular disease in chronic renal disease. Am J Kidney Dis 32:S112-S119, 1998 (suppl 3)

Incidence of End Stage Renal Disease Incidence of End Stage Renal Disease (ESRD) According to Primary Diagnosis(ESRD) According to Primary Diagnosis

USRDS. 2004. Available at: http://www.usrds.org/atlas.htm.

Co-Morbidities of the ESRD Co-Morbidities of the ESRD PopulationPopulation

80% of dialysis 80% of dialysis patients who have patients who have an MI are dead an MI are dead within 3 years within 3 years

Herzog CA, Ma JZ, Collins AJ: Poor long-term survival after acute myocardial infarction among patients on long-term dialysis. N Engl J Med 339:799-805, 1998

Life ExpectancyLife Expectancy

Patients Diagnosed with CKD ± DM Have a Patients Diagnosed with CKD ± DM Have a Greater Likelihood of Death than ESRDGreater Likelihood of Death than ESRDFirst nephrologist visit at an outpatient clinic (n=20,363)First nephrologist visit at an outpatient clinic (n=20,363)

Percent of

patients (%)

Status in the entry period

100

80

60

40

20

0NDM/Non-CKD

90.33

8.27

83.75

12.40

68.24

20.42

11.34

60.73

21.60

17.58

DM/Non-CKD NDM/CKD DM/CKD

n=11,698 3,637 2,884 2,144No EventsESRDDeath

CKD Principle #1CKD Principle #1There are close to 20 million patients in the U.S. There are close to 20 million patients in the U.S. with CKD stages 1-5. There are perhaps another with CKD stages 1-5. There are perhaps another 20 million patients in the U.S. at risk for CKD20 million patients in the U.S. at risk for CKD– Many of these patients are not under a physician’s care, so Many of these patients are not under a physician’s care, so

targeted screening of at-risk populations is cost-effectivetargeted screening of at-risk populations is cost-effective– For those patients under a physician’s care (usually a PCP), For those patients under a physician’s care (usually a PCP),

most of the CKD interventions can and should be delivered by most of the CKD interventions can and should be delivered by the PCPthe PCP

– Early referral of a CKD patient to a nephrologist (when GFR Early referral of a CKD patient to a nephrologist (when GFR <60 ml/min/1.73m<60 ml/min/1.73m22) to provide strategic guidance is associated ) to provide strategic guidance is associated with improved outcomeswith improved outcomes

GFRGFRSerum Creatinine is not very predictive of renal functionSerum Creatinine is not very predictive of renal functionGFR affected by age, gender, weight, & raceGFR affected by age, gender, weight, & raceFormulas exist to estimate GFR that are more accurate Formulas exist to estimate GFR that are more accurate than 24 hour urine collectionthan 24 hour urine collectionMDRDMDRD– GFR (mL/min/1.73 m2) = GFR (mL/min/1.73 m2) = 186186 x (Scr)-1.154 x (Age)-0.203 x x (Scr)-1.154 x (Age)-0.203 x

(0.742 if female) x (1.210 if African American) (0.742 if female) x (1.210 if African American)

Crockroft-GaultCrockroft-Gault–       For men: CrCl = [(140 - Age) x Weight (kg)]/SCr x 72For men: CrCl = [(140 - Age) x Weight (kg)]/SCr x 72–       For women: CrCl = ([(140 - Age) x Weight (kg)]/SCr x 72) x For women: CrCl = ([(140 - Age) x Weight (kg)]/SCr x 72) x

0.850.85

GFRGFR

Lin J, Knight EL, Hogan ML, Singh AK: A Comparison of Prediction Equations for Estimating Glomerular Filtration Rate in Adults without Kidney Disease. J Am Soc Nephrol 14: 2573–2580, 2003

50 y/o AA Female referred from Family 50 y/o AA Female referred from Family Practitioner for renal arteriography Practitioner for renal arteriography because of uncontrolled hypertensionbecause of uncontrolled hypertensionSignificant history: Type 2 DM & Significant history: Type 2 DM & HypertentionHypertentionSerum Cr 1.4Serum Cr 1.4What would you do?What would you do?

– MRAMRA– Hydrate overnight Hydrate overnight – BicarbBicarb– N-Acetyl CystineN-Acetyl Cystine– Use alternative contrast agentsUse alternative contrast agents– Nothing special—Do arteriogram & limit Nothing special—Do arteriogram & limit

contrast as much as possiblecontrast as much as possible

Calculated MDRD GFRCalculated MDRD GFR

GFR (mL/min/1.73 m2) = GFR (mL/min/1.73 m2) = 186186 x (Scr)- x (Scr)-1.154 x (Age)-0.203 x (0.742 if female) x 1.154 x (Age)-0.203 x (0.742 if female) x (1.210 if African American) (1.210 if African American) GFR = 186 x 1.4GFR = 186 x 1.4-1.154-1.154 x 50 x 50-0.203-0.203 x 0.742 x x 0.742 x 1.2101.210

51

CKD Principle #2CKD Principle #2

Use of serum creatinine as a marker of kidney Use of serum creatinine as a marker of kidney function grossly underestimates the presence function grossly underestimates the presence and severity of CKDand severity of CKD– Formulas for GFR (MDRD) or creat. clearance Formulas for GFR (MDRD) or creat. clearance

(Cockcroft-Gault) are more sensitive, easy to use and (Cockcroft-Gault) are more sensitive, easy to use and do not require 24 hour urine collectiondo not require 24 hour urine collection

– 24 hour urine collection for creat. clearance is 24 hour urine collection for creat. clearance is notoriously inaccuratenotoriously inaccurate

– All labs should be encouraged to report renal function All labs should be encouraged to report renal function as GFR based on MDRD formula (age, gender and as GFR based on MDRD formula (age, gender and race)race)

Optimal CKD Patient CareOptimal CKD Patient Care

Early Detectionof CRF

Interventions thatdelay progression

ACE inhibitors

BP control

Blood sugar control

Protein restriction

Prevention of uremic complications

Malnutrition

Anemia

Osteodystrophy

Acidosis

Modification ofcomorbidity

Cardiac disease

Vascular disease

Neuropathy (in diabetics)

Retinopathy (in diabetics)

Preparation for RRT

Education

Informed choice of RRT

Timely access placement

Timely initiation of dialysis

Assessment for Renal Assessment for Renal Replacement TherapyReplacement Therapy

TransplantTransplantPeritoneal DialysisPeritoneal DialysisHemodialysisHemodialysis– AVFAVF– GraftGraft

Synthetic MaterialSynthetic MaterialBiological Material (Bovine Carotid Artery)Biological Material (Bovine Carotid Artery)

– CatheterCatheter

Fistula FirstFistula First

CMS, the ESRD Networks, the renal CMS, the ESRD Networks, the renal community, and IHI will work together to community, and IHI will work together to increase the likelihood that every eligible increase the likelihood that every eligible patient will receive the most optimal form of patient will receive the most optimal form of vascular access for that patient. In the vascular access for that patient. In the majority of cases, this will be a fistula. majority of cases, this will be a fistula.

Incident PatientsIncident Patients

Prevalent PatientsPrevalent Patients

NVAII GoalsNVAII Goals

By June 2006By June 2006– 40% prevalent 40% prevalent

fistulasfistulas– 50% incident 50% incident

fistulasfistulas

By June 2009By June 2009– 66% prevalent 66% prevalent

fistulasfistulas

NVAII Change ConceptsNVAII Change Concepts1.1. Routine CQI review of Routine CQI review of

vascular accessvascular access2.2. Early referral to Early referral to

nephrologistnephrologist3.3. Early referral to surgeon Early referral to surgeon

for “AVF only”for “AVF only”4.4. Surgeon selectionSurgeon selection5.5. Full range of appropriate Full range of appropriate

surgical approachessurgical approaches

6.6. AVF placement in AVF placement in catheter patientscatheter patients

7.7. Cannulation trainingCannulation training8.8. Monitoring and Monitoring and

surveillancesurveillance9.9. Continuing education: Continuing education:

staff and patientstaff and patient10.10.Secondary AVFs in AVG Secondary AVFs in AVG

patientspatients11.11.Outcomes feedbackOutcomes feedback

AlgorithmsAlgorithmsVenography or Venography or ultrasound in all ultrasound in all catheter & graft catheter & graft patientspatients– Look for conversionsLook for conversions

Algorithms to Algorithms to evaluate veins at evaluate veins at Stage 3 & 4Stage 3 & 4– Physical ExamPhysical Exam– UltrasoundUltrasound– Venography where Venography where

neededneeded

AVF TypesAVF Types

Take Home MessageTake Home Message

CKD represents a much larger problem CKD represents a much larger problem than ESRDthan ESRDUse of calculated GFR to assess renal Use of calculated GFR to assess renal function will help us identify patients at risk function will help us identify patients at risk for ESRDfor ESRDIt is incumbent on us to identify patients It is incumbent on us to identify patients who can have fistulas placed at stage 3 & who can have fistulas placed at stage 3 & 4 CKD4 CKD