Chronic Kidney Disease Hasan Khamash MD

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.